IngléS TéCnico I 061009 Dm
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IngléS TéCnico I 061009 Dm

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All about Diabetes, explanation and diet

All about Diabetes, explanation and diet

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    IngléS TéCnico I 061009 Dm IngléS TéCnico I 061009 Dm Presentation Transcript

    • October 6th, 2009 Profesor: Karla M. López Ahumada
    • TODAY´S GOALS
      • Return homework and quizzes
      • Take quizz 7 for those justified
      • Share information about the first nutrición conference in Monterrey
      • Cover all aspects of diabetes mellitus
    • Diabetes Mellitus
      • A heterogeneous group of disorders characterized by an elevation in the level of glucose in the blood.
      • In Diabetes there may be a decrease in the body’s ability to respond to insulin and/or a decrease or absence of insulin produced by the pancreas.
      • It is characterized by hyperglycemia, glycosuria and ketonuria.
    • Diabetes Mellitus
      • The resulting hyperglycemia may lead to acute metabolic complications such as diabetic ketoacidosis and hyperosmolar nonketotic syndrome.
      • Long term hyperglycemia may contribute to chronic microvascular complications, neuropathic complications, and macrovascular diseases.
    • How will you know if you are a diabetic?
      • If you urinate frequently, experience excessive thirst and unexplained weight loss.
      • If your casual blood sugar (plasma glucose) level is higher than 200mg/dl.
      • If you have fasting plasma glucose level of not more than 120mg/dl.
      • children of diabetics
      • obese people
      • people with hypertension
      • people with high cholesterol levels
      • people with sedentary lifestyles
    • Types of Diabetes
      • Type 1 : Insulin-dependent diabetes mellitus
      • Type 2 : Non-insulin-dependent diabetes mellitus
      • Gestational diabetes mellitus
    • Types of Diabetes
      • Type 1: About 5% to 10% of people with Diabetes. A form of diabetes wherein there is inadequate amounts of insulin are produced by the pancreas, resulting in the need for insulin injections to control the blood glucose. It is also characterized by sudden onset usually before the age of 30 years.
      • Type 2: About 90% to 95% of people with Diabetes. Cause by a decrease in the sensitivity of the cells to insulin and the decrease in the amount of insulin produced. It can be treated with diet, oral hypoglycemic agents and insulin injections. It occurs most frequently in people who are over 30 years of age and obese.
    • Epidemiology
      • In México, diabetes has been the first leading cause of death since the year 2000.
      • In the U.S., diabetes is the third leading cause of death by disease, mostly because of the high rate of coronary artery disease among people with diabetes.
      • Diabetes is the leading cause of new blindness (among 25 to 74 years old) and nontraumatic amputations in the United States.
      • 25% of patients on dialysis have diabetes.
      • Hispanic, black, and some Native American populations have a higher rate of diabetes than the white populations.
    • Epidemiology
      • Diabetes in 2007
      • 23.6 million — Number of Americans who had diabetes
      • 12.2 million — Number of Americans 60 and older with diabetes
      • 5.7 million — Number of undiagnosed cases of diabetes
      • 1.6 million — Number of new cases of diabetes in adults
      • 186,300 — Number of people younger than 20 with diabetes
      • $174 billion — Economic cost of diabetes
      • Source: American Diabetes Association
    • Local Epidemiology
      • Find local statistics of diabetes
        • Year 2006 or newer
        • % of diabetics by state, gender or age
        • Identify your source, always!
        • Be creative when designing a diagram
    • What is Insulin?
      • Hormone secreted by the beta cells, which are one of four types of cells in the islets of the pancreas. It is considered to be an anabolic, or storage, hormone. When a meal is eaten, insulin secretion increases and moves glucose from the circulation into muscle, liver, and fat cells.
      • During “fasting periods” (between meals and overnight) there is a lower production of insulin accompanied by an increased release of another pancreatic hormone the glucagon. The net effect of the balance between insulin and glucagon levels is to maintain a constant level of glucose in the blood through release of glucose from the liver.
    • The Pancreas….
    • How does it work?
    • Insulin Functions….
      • Stimulates storage of glucose in the liver and muscle (in the form of glycogen).
      • Enhances storage of dietary fat in adipose tissue.
      • Accelerates transport of amino acids (derived from dietary protein) into the cells.
      • Insulin also inhibits the breakdown of stored glucose, protein, and fat.
    • Classification of Diabetes Mellitus and Related Glucose Intolerance Current Classification Previous Classifications Clinical Characteristics Type 1: Insulin – dependent diabetes mellitus (IDDM) Juvenile diabetes Ketosis prone diabetes Brittle diabetes Etiology includes genetic, immunologic, and or environmental factors Need insulin to preserve life Acute complication of hyperglycemia: diabetic ketoacidosis Type 2: Non-insulin-dependent diabetes (NIDDM) Adult onset diabetes Maturity onset diabetes Ketosis resistant diabetes Stable diabetes Etiology includes obesity, heredity, and environmental factors Oral hypoglycemic agents may improve blood glucose level Acute complication: hyperosmolar nonketotic syndrome
    • Classification of Diabetes Mellitus and Related Glucose Intolerance Current Classification Previous Classifications Clinical Characteristics Diabetes mellitus associated with other conditions or syndromes Secondary diabetes Accompanied by conditions known or suspected to cause the disease: pancreatic diseases; hormonal abnormalities; drug such as glucocorticoids and estrogen containing preparations Gestational diabetes Gestational diabetes Onset during pregnanacy 2 nd and 3 rd trimester Due to hormones secreted by placenta , which inhibit the action of insulin Risk factor: obesity, age over 30, family hx of diabetes, previous large babies (over 9lb)
    • Classification of Diabetes Mellitus and Related Glucose Intolerance Current Classification Previous Classifications Clinical Characteristics Impaired glucose intolerance Borderline diabetes Chemical diabetes Subclinical diabetes Asymptomatic diabetes Blood glucose levels between normal and that of diabetes 25% eventually develop diabetes May be obese or nonobese; obese should reduce weight Previous abnormality of glucose tolerance Potential abnormality of glucose tolerance Latent diabetes Prediabetes Previous history of hyperglycemia (eg. Pregnancy or illness) No hx of glucose intolerance but increase risk of diabetes due to family hx, obese, race
    • Etiology of Type 1 Diabetes
      • Combination of Genetic, Immunologic, and possibly Environmental factors contribute to beta cells destruction.
      • Genetic – People do not inherit type 1 DM itself; rather, they inherit a genetic predisposition, or tendency, toward developing type 1 DM. This genetic tendency has been found in people with certain HLA (human leukocyte antigen) types. 95% of patients with type 1 diabetes exhibit specific HLA types (DR3 or DR4). The risk of developing type 1 DM is increased 3-5 times in people who have one of these two HLA types.
    • Etiology of Type 1 Diabetes
      • Immunologic – Abnormal response in which antibodies are directed against normal tissues as if they are foreign. Auto antibodies against islet cells and against endogenous (internal) insulin have been detected in people at the time of diagnosis.
      • Environmental – Certain viruses or toxins may precipitate the autoimmune process that leads to beta cell destruction.
    • Etiology of Type 2 Diabetes
      • The exact mechanisms that lead to insulin resistance and impaired insulin secretion in type 2 are still unknown at this time. But they say Genetic factor play an important role in developing insulin resistance.
      • There are certain risk factors:
      • Age (insulin resistance tends to occur with age over 65)
      • Obesity
      • Family history
      • Ethnic group (Hispanic and American Indians)
    • World Health Organization Diagnostic Criteria for Diabetes Mellitus in Adults
      • On at least two occasions:
      • Random plasma glucose > 200mg/dl
      • Fasting plasma glucose > 140mg/dl
      • 2-hour sample during 75g OGTT (Oral Glucose Tolerance Test)
      • > 200mg/dl
      • OGTT – The patient ingest high CHO (150-300g) meals for 3 days preceding the test. After an overnight fast, a blood sample is drawn. Then a 75g CHO load, usually in the form of carbonated sugar beverage (Glucola), is given to patient. The patient is instructed to sit quietly, avoid exercise, smoking, coffee, and any other oral intake except water. WHO recommends that after 2 hours a blood sample is drawn after glucose ingestion.
    •  
    • Complications of Diabetes
      • Acute Complications: result from an imbalance in the treatment regimen.
      • Hypoglycemia (low blood sugar), which is also called insulin reaction or insulin shock.
      • Hyperglycemia (high blood sugar), which, if uncontrolled, may lead to diabetic ketoacidosis (DKA) in type 1 diabetes or hyperosmolar nonketotic syndrome (HNKS) in type 2 diabetes.
    • Complications of Diabetes
      • Chronic Complications of type 1 and type 2 diabetes generally occur 10 to 15 years after the onset of diabetes.
      • Macrovascular (large vessel) disease – affecting coronary peripheral vascular, and cerebrovascular circulations.
      • Microvascular (small vessel) disease – affecting the eyes (retinopathy) and kidneys (nephropathy).
      • Neuropathic diseases – affecting sensorimotor and autonomic nerves and contributing to such problems aqs impotence and foot ulcers.
    • Misconceptions Related to Diabetes and Its Treatment Misconception Reality
      • Diabetes is caused by eating too much sugar.
      • Sugar is found only in dessert foods.
      • The reason that diabetes develops initially is that there is a decrease in the amount of insulin in the body or a decrease in the ability of insulin to control the blood glucose level.
      • There are several different types of sugars (simple carbohydrates) that increase blood glucose level. Dessert foods often contain sucrose. Even if the juice is labeled “unsweetened”, there is still natural fruit sugar in the product, which causes elevations in the glucose level.
    • Misconceptions Related to Diabetes and Its Treatment Misconception Reality
      • The only diet change needed in the treatment of diabetes is to stop eating sugar.
      • Once insulin injections are started (for treatment of type 2 diabetes) they can never be discontinued.
      • It is important for the patient to realize that it is not feasible or advisable to remove all sources of sugar from the diet. There are nutritious foods such as fruit that contain sugar and that should be included in the meal plan.
      • During period of acute stress (such as illness/surgery) or when receiving certain medications that cause elevations in blood glucose, some patients with type 2 diabetes will require insulin.
    • Misconceptions Related to Diabetes and Its Treatment Misconception Reality
      • If increasing doses of insulin are needed to control the blood glucose, the diabetes must be getting “worse”.
      • Blood glucose levels remain the same throughout the day.
      • Explain to the patient that, unlike other medications that are given in standard doses, there is not a standard dose of insulin that is effective for all patients. It is imp’t to instruct patients that many diff. factors may affect the ability of insulin to lower glucose such as obesity,puberty,illness.
      • Explain to patients that there is normally a variation in blood glucose levels, with the lowest level before meals and the highest 1 to 2 hours after eating.
    • Misconceptions Related to Diabetes and Its Treatment Misconception Reality
      • Insulin causes blindness (or other diabetic complications.
      • Urine and blood glucose testing are interchangeable. (they provide the same information)
      • It must be explained to the patient that factors such as elevated blood glucose and elevated blood pressure levels (and not insulin therapy) contribute to some of the diabetic complications.
      • Explain to the patient that directly testing the blood is the most accurate method of measuring the glucose level. The urine glucose test, w/c measures the amt. of glucose that has spilled into the urine since the bladder last emptied, is only indirect way of determining glucose level in the blood.
    • Misconceptions Related to Diabetes and Its Treatment Misconception Reality
      • Insulin must be injected directly into the vein.
      • There is extreme danger in injecting insulin if there are any air bubbles in the syringe.
      • The patient must be reassured that insulin is injected into the fat tissue on the back of the arm (or on the abdomen, thigh, or hip) and that the needle is much shorter than that used for venipuncture.
      • This maybe related to misconception that insulin is injected directly to the vein. Reassure patients that the main danger in having air bubbles in the insulin syringe is that the amount of insulin being injected is less than the required dosage.
    • Morning Hyperglycemia
      • Insulin Waning – Progressive rise in blood glucose from bedtime to morning. TT: Increase evening dose of intermediate or long acting insulin.
      • Dawn Phenomenon – Relatively normal blood glucose until about 3am when the level begins to rise. TT : Change time of injection of evening intermediate acting insulin from dinner time to bedtime.
      • Somogyi Effect – Normal or elevated glucose at bedtime, a decrease at 2-3am to hypoglycemic levels, and a subsequent increase caused by the production of counter regulatory hormones. TT : Decrease dose of evening intermediate acting insulin or increase evening snack.
    • Foot and Leg Problems in Diabetes
      • 55% to 75% of lower extremity amputations are performed on people with Diabetes. 50% of these amputations are preventable, provided patients are taught preventive foot care measures and practice preventive foot care on a daily basis.
      • Three diabetic complications contribute to the increased risk of foot infections. They are:
      • A. Neuropathy – Sensory neuropathy leads to loss of pain and pressure sensation, and autonomic neuropathy leads to increased dryness and fissuring of the skin (secondary to decreased sweating).
    • Foot and Leg Problems in Diabetes
      • B. Peripheral vascular disease – Poor circulation of the lower extremities contributes to poor wound healing and the development of gangrene.
      • C. Immunocompromise – Hyperglycemia impairs the ability of specialized leukocytes to destroy bacteria. Thus, in poorly controlled diabetes there is a lowered resistance to certain infections.
      • Diabetic foot ulcer begins with a soft tissue injury of the foot, the injury or fissure may go unnoticed until a serious infection has developed. Drainage, swelling, redness (from cellulitis) of the leg, or gangrene may be the first sign of foot problems that the patient notices
    • Foot and Leg Problems in Diabetes
      • Treatment of foot ulcers involves bed rest, antibiotics, and debridement.
      • In peripheral vascular diseases, foot ulcers may not heal because of the decreased ability of oxygen, nutrients, and antibotics to reach the injured tissue. Amputation may be necessary to prevent further spread of infection.
      • Foot Assessment and Foot Care instruction are most important in dealing with patient who are high risk of developing foot ulcers.
      • Duration of diabetes over 10 years
      • Age over 40 years
      • History of smoking
      • Decreased peripheral pulses
      • Decreased sensation
      • Anatomic deformities or pressure areas (such as calluses)
      • History of previous foot ulcers or amputation
    • Foot Care….
      • Preventive foot care includes properly bathing, drying, and lubricating feet (care must be taken not to allow moisture to accumulate from water or lotion between the toes.)
      • Feet must be inspected on a daily basis for any redness, blisters, fissures, calluses or ulcerations.
      • The interior surface of the shoes should be inspected for any rough spots or foreign objects.
      • Feet should be examined on a regular basis by a podiatrist, physician, or nurse.
    • Foot Care….
      • Patients with thick toenails should see the podiatrist routinely for shaving of calluses and trimming of nails.
      • Patients should be taught to wear well-fitting, closed toe shoes.
      • High risk behaviors should be avoided, such as walking barefoot, using heating pads on the feet, wearing open toed shoes, and shaving calluses.
      • Toenails should be trimmed straight across without rounding the corners.
      • Amputations can be divided into two types: minor and major.
      • Minor or limited amputations are amputations where only a toe or part of the foot is removed.
      • A ray amputation is a particular form of minor amputation where a toe and part of the corresponding metatarsal bone is removed; and the wound is usually left open to heal. This sort of operation is performed frequently for foot infections in patients with diabetes. A partial foot amputation through the metatarsal bones is called transmetatarsal (TM) amputation.
    • A Gangrene Foot….
    • Transmetatarsal (TM) amputation
    • Types (Levels) of Amputations
      • Major amputations are amputations where part of the leg is removed.
      • These are usually:
      • below the knee, called transtibial (TT) amputation, or
      • above the knee, called transfemoral (TF) amputation.
      • Occasionally an amputation of just the foot can be performed with a cut through the ankle joint.
      • Below the knee operation (transtibial amuptation), the bone in the lower leg (tibia) is divided about 12-15 cm below the knee joint. This produces a good size stump to which a prosthesis can be fitted.
    • BELOW KNEE AMPUTATION DUE TO ISCHEMIA NECROSIS
    • What can you do to control your blood sugar?
      • 1. Diet Therapy
      • * Avoid simple sugars like cakes and chocolates. Instead have complex carbohydrated like rice, pasta, cereals and fresh fruits. * Do not skip or delay meals. It causes fluctuations in blood sugar levels. * Eat more fiber-rich foods like vegetables. * Cut down on salt. * Avoid alcohol. Dietary guidelines recommend no more than two drinks for men and no more than one drink per day for women.
    • 2. Exercise Regular exercise is an important part of diabetes control. Daily exercise . . . * Improves cardiovascular fitness * Helps insulin to work better and lower blood sugar * Lowers blood pressure and cholesterol levels * Reduces body fat and controls body weight Exercise at least 3 time a week for ate least 30 minutes each session. Always carry quick sugar sources like candy or softdrink to avoid hypoglycemia (low blood sugar) during and after exercise.
    • 3. Control your weight If you are overweight or obese, start weight reduction by diet and exercise. This improves your cardiovascular risk profile. * It lowers your blood sugar * It improves your lipid profile * It improves your blood pressure control 4. Quit smoking. Smoking is harmful to your health.
    •  
    • There are drug therapies using oral hypoglycemic agents. Your doctor can prescribe one or two agent, depending on which is appropriate for you.
      • 1. Sulfonylurea – Glibenclamide, Gliclazide, Glipizide, Glimepiride, Repaglinide
      • 2. Biguanide – Metformin
      • 3. Alpha-glucosidase Inhibitors – Acarbose
      • 4. Thiazolidindione – Troglitazone, Rosiglitazone, Proglitazone.
    • Insulin Therapy….
      • It is controlled by the M.D. but is also monitored by the RD or CDE by encouraging the patient to keep a food and insulin diary.
    • Remember
      • If you have the classic symptoms of diabetes:
      • * See your doctor for blood sugar testing * Start dieting * Eat plenty of vegetables * Avoid sweets such as chocolates and cakes * Cut down on fatty foods * Exercise regularly * If you are obese, try to lose some weight * Avoid alcohol drinking and stop smoking * If you are hypertensive, consult your doctor for advice and management
      • Eating a healthy diet can:
        • Help you control your blood sugars and blood lipids
        • Help you maintain a healthy weight or lose weight if you are overweight
        • Allow you to take less medication or avoid taking medication for your diabetes
      • Eating a healthy diet can:
        • Prevent complications from high blood sugars like nerve problems, kidney problems, and vision problems
        • Prevent other complications like heart disease and circulatory problems
      • Every person with diabetes should receive medical nutrition therapy based on his/her medical needs
      • Your dietitian may suggest very specific goals for your weight, diet, and exercise depending on your health status
      • Lose weight if you are overweight
      • Exercise to promote or maintain weight loss
      • Monitor carbohydrate intake to maintain blood sugar control
      • Obtain carbohydrates mainly from fruits, vegetables, whole grains, legumes, and low-fat or skim milk
      Source: Standards of Medical Care in Diabetes-2007. Position Statement of the American Diabetes Association. Diabetes Care 30 (S1), January 2007.
      • Consume at least 130 grams carbohydrate per day (do not use low-carbohydrate diets to treat diabetes)
      • Use sugar substitutes if desired
      • Limit saturated fat, trans fat, and dietary cholesterol
      Source: Standards of Medical Care in Diabetes-2007. Position Statement of the American Diabetes Association. Diabetes Care 30(Supplement 1): S4-S41, January 2007.
      • Lose weight if you are overweight
        • Lose weight slowly and safely, 1-2 pounds weekly (____ kg?)
        • Enjoy foods from all food groups. Avoid fad diets that eliminate any specific foods or groups of foods.
        • Eat smaller portions and exercise more
      • Exercise to promote or maintain weight loss (consult with your doctor before beginning)
        • 30 minutes most days of the week is recommended (____ days?)
        • Include aerobic exercise and resistance training for the best results
        • Start slowly and increase the duration and intensity of exercise if you are new to exercise.
      Source: Standards of Medical Care in Diabetes-2007. Position Statement of the American Diabetes Association. Diabetes Care 30(Supplement 1): S4-S41, January 2007.
        • Monitor carbohydrate intake to maintain blood sugar control
          • Limit your carbohydrate intake to what is suggested by your dietitian
          • Use carbohydrate counting, the exchange system, or other methods to estimate your carbohydrate intake
      Source: Nutrition Recommendations and Interventions for Diabetes. A Position Statement of the American Diabetes Association. Diabetes Care 30 (Supplement 1):S48-S63, January 2007.
      • Obtain carbohydrates mainly from fruits, vegetables, whole grains, legumes, and low-fat or skim milk.
        • These foods are the best carbohydrate sources
          • They are usually high in fiber and high in nutrients your body needs
      Source: Nutrition Recommendations and Interventions for Diabetes. A Position Statement of the American Diabetes Association. Diabetes Care 30 (Supplement 1):S48-S63, January 2007.
      • Carbohydrate sources
        • Even sugar and sweetened foods can be included in your diet when you have diabetes.
          • Substitute them for another carbohydrate in your diet now and then
          • These food are “empty calories” so should be limited
      Source: Nutrition Recommendations and Interventions for Diabetes. A Position Statement of the American Diabetes Association. Diabetes Care 30 (Supplement 1):S48-S63, January 2007.
      • Consume at least 130 grams of carbohydrate each day
        • Low-carbohydrate diets are not recommended for diabetes management
        • Carbohydrates contain important nutrients
        • Choose most of your carbohydrates from fruits, vegetables, and whole grains.
      Source: Nutrition Recommendations and Interventions for Diabetes. A Position Statement of the American Diabetes Association. Diabetes Care 30 (Supplement 1):S48-S63, January 2007.
      • Use sugar substitutes if desired
        • Use only sugar substitutes that are approved by the FDA
        • Sugar substitutes can help you enjoy sweet treats more often
        • Sugar substitutes don’t appear to cause weight loss or control blood sugars
      Source: Nutrition Recommendations and Interventions for Diabetes. A Position Statement of the American Diabetes Association. Diabetes Care 30 (Supplement 1):S48-S63, January 2007.
      • Limit saturated fats, trans fat, and dietary cholesterol
        • These types of dietary fats and cholesterol can contribute to heart disease, which is related to diabetes
        • When you use fats, use liquid oils instead of solid fats when possible .
      • Trans fat are produced by the food industry by taking liquid oils and changing them into solid fats.
        • This process improves the shelf life and stability of flavors of processed foods
      • Trans fats are found mainly in packaged and processed foods.
      • To limit trans fats
        • Limit use of packaged crackers and cookies
        • Limit use of commercial bakery products like cakes, cookies, etc
        • Use soft margarine instead of stick margarine
        • Read food labels for trans fats
      • Dietary cholesterol is found mainly in animal foods.
        • By limiting saturated fats you will also limit dietary cholesterol
      • Fats are higher in calories than carbohydrates, so eating less fat can help you lose weight.
      • Use lean meats and poultry and include fish, nuts, and legumes to help reduce your intake of saturated fats and cholesterol
      • Where do I start?
        • Talk to your doctor, dietitian, and diabetes educator about which changes are most important for you
        • Start slowly by changing your habits one at a time
        • Seek support from your dietitian and/or diabetes support group
      • Good nutrition is one of the keys to managing Type 2 Diabetes
      • Nutrition guidelines for Type 2 Diabetes focus on controlling carbohydrate and fat intake
      • Weight management and exercise are also key
      • Seek help to set and reach your nutrition and exercise goals
    • American Diabetes Association, Food exchanges
      • Study for quizz 8
      • Good luck!