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Chapter 020

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  • With professional help, individuals with diabetes can learn to practice good self-care skills that reduce the risk of long-term complications.
  • Without insulin, glucose accumulates in the bloodstream.
  • Type 1 diabetes tends to develop rapidly and is more severe and instable than other forms of diabetes.
  • The onset of type 1 diabetes occurs rapidly among children and adolescents.
  • Name some examples of medications used to treat type 2 DM.
  • Ask students to describe a typical person at risk for developing type 2 DM.
  • Women with gestational diabetes are taught to follow a careful diet and monitor blood glucose, blood pressure, and urinary protein.
  • List types of drugs and chemicals that cause secondary diabetes.
  • What are some underlying conditions that are often present with impaired glucose tolerance? (Hypercholesterolemia, obesity, hypertension)
  • Explain how an accurate nursing assessment and health history assist in identifying patients at risk.
  • Define the normal range for laboratory test results.
  • Diabetes was traditionally considered a disease of carbohydrate metabolism, but it actually involves all three of the energy-yielding nutrients: carbohydrate, fat, and protein.
  • Case Study:Mr. Jones is a 45-year-old black male. He is 25 lbs overweight. He also has a family history of diabetes. His most recent lab work reveals an elevated fasting blood sugar, elevated total cholesterol, and low HDL level.
  • Risk factors for diabetes include:Family history of diabetesOverweightRaceElevated fasting blood sugarElevated lipid levels
  • Additional screening tools for diabetes include:Glucose tolerance testGlucose in the urineA1C
  • Increased thirstIncreased urinationIncreased hungerUnusual weight loss (type 1)Unusual weight gain (type 2)
  • The backup source of glycogen stored in the liver and muscles is constantly turned over.
  • What are the islets of Langerhans? (Specialized cells located in the pancreas)
  • Islets of Langerhans, located in the pancreas.
  • Which pancreatic cells produce insulin? (Beta cells)
  • Which pancreatic cells produce glucagon? (Alpha cells)
  • Describe how all three hormones relate to one another.Where in the pancreas is somatostatin produced? (Delta cells)
  • These are the three macronutrients.
  • Insulin normally attaches to insulin receptor sites on cells throughout the body and assists in the migration of glucose into the cells.
  • An excess of ketones in the body results in diabetic ketoacidosis.
  • The loss of protein causes weight loss, muscle weakness, urinary nitrogen loss.
  • The long-term complications of diabetes result from hyperglycemia, which causes microvascular and macrovascular dysfunction in major organs.
  • List complications associated with uncontrolled diabetes.
  • The importance of self-care has led to a new emphasis on education that encourages more self-care responsibility.
  • Pregnancy presents a special challenge to women with diabetes because they must meet the increased physiologic demands of pregnancy while battling the manifestations of diabetes.
  • Glycemic control is the primary focus in diabetes management.
  • A plan for medical nutrition therapy must take into consideration the individual’s personal and cultural food preferences.
  • Discuss the importance of glycemic control before, during, and after exercise.
  • See the inside cover of the text for DRIs for children and adults; make appropriate adjustments for overweight adults.
  • The diet for a person with diabetes is always based on the normal nutrition needs for that person.
  • Are sugar substitutes allowed if a patient has diabetes? (Yes, in moderation. Caloric sweeteners should be accounted for in the meal.)
  • A goal of proper food distribution is to prevent extreme high and low blood glucose levels.
  • Diet planning should consider school and work activities, sports, social events, and stressful activities.
  • Individuals should consume additional carbohydrates during exercise as needed to prevent hypoglycemia.
  • Blood glucose monitoring results will dictate the changes to food distribution, medications, and exercise.
  • Why must individual preferences and cultural background be taken into consideration? (The diet must be palatable to the individual and must make use of foods known to the cultural group.)
  • Both dietitians and people with diabetes use the food exchange system to meet the patient’s energy and nutrient needs.
  • People with diabetes must time their insulin doses when eating out to coincide with food arrival.
  • The ultimate goal of DSME is to improve health status and quality of life.
  • People with diabetes will be more likely to make healthy food choices when they understand that how to food plan helps them maintain good blood glucose control.
  • For individuals at risk for type 2 diabetes or with prediabetes: Decrease risk of diabetes and cardiovascular diseasePromote healthy food choices and physical activity Maintain moderate weight lossIndividuals with diabetesAchieve and maintain:Blood glucose levels as safely as possibleLipid and lipoprotein profile Blood pressure levelsPrevent, or at least slow, the rate of chronic complications Address individual nutrition needs Maintain the pleasure of eatingNutrition therapyTotal energy balanceNutrient balanceFood distribution balancePersonal dietTotal kilocalories of energy balanceRatio of carbohydrate, fat, proteinDaily food distribution pattern
  • Other resources include certified diabetes educators, hospital and clinic dietitians, dietitians in private practice, public health nutritionists, and local chapters of the American Diabetes Association.
  • Patients and health care providers can use the American Association of Diabetes Educator’s Web site to locate a specialist.
  • Transcript

    • 1. Williams' Basic Nutrition & Diet Therapy Chapter 20 Diabetes Mellitus Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 1 14th Edition
    • 2. Lesson 20.1: Diabetes Mellitus as a Metabolic Disorder  Diabetes mellitus is a metabolic disorder of glucose metabolism with many causes and forms.  A consistent, sound diet is a major keystone of diabetes care and control. 2Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    • 3. Introduction (p. 400)  11% of U.S. adults have diabetes  Seventh leading cause of death in the United States  Historically, victims died at young age  With proper care, people with diabetes can live long, fulfilling lives 3Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    • 4. Nature of Diabetes (p. 400)  Defining factor  Glucose is primary source of energy for the body  Insulin is needed to be taken out of blood and transferred into cells  People with diabetes either do not produce insulin or cannot effectively use insulin produced  Diabetes: group of metabolic diseases characterized by hyperglycemia 4Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    • 5. Classification of Diabetes Mellitus and Glucose Intolerance (p. 400)  Type 1 diabetes mellitus  Accounts for 5% to 10% of cases  Previously called insulin-dependent or juvenile- onset diabetes  Severe, unstable form 5Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    • 6. Classification of Diabetes Mellitus and Glucose Intolerance (cont’d) (p. 401)  Type 1 diabetes mellitus (cont’d)  Caused by autoimmune destruction of pancreatic cells  Can occur at any age  Requires exogenous insulin 6Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    • 7. Type 2 Diabetes Mellitus (p. 401)  Accounts for 90% to 95% of cases  Previously called adult-onset or non–insulin- dependent diabetes  Initial onset usually after age 40 years  Now being diagnosed in children 7Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    • 8. Type 2 Diabetes Mellitus (cont’d) (p. 402)  Strong genetic link  Prevalent in older, obese people  Caused by insulin resistance or defect  Usually treated with diet, exercise 8Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    • 9. Gestational Diabetes (p. 402)  Temporary form of disease occurring in pregnancy  Presents complications for mother and fetus/infant  Must be carefully monitored and controlled 9Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    • 10. Other Types of Diabetes (p. 404)  Causes  Genetic defect  Pancreatic conditions or disease  Endocrinopathies: imbalance with other hormones in the body  Drug/toxin induced or chemical induced 10Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    • 11. Impaired Glucose Tolerance (p. 404)  Above normal fasting blood glucose but not high enough to be diabetes  A risk factor for type 2 diabetes  Underlying conditions often present 11Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    • 12. Symptoms of Diabetes (p. 404)  Initial signs  Increased thirst  Increased urination  Increased hunger  Unusual weight loss (type 1)  Unusual weight gain (type 2) 12Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    • 13. Symptoms of Diabetes (cont’d) (p. 405)  Laboratory test results  Glycosuria (sugar in urine)  Hyperglycemia (elevated blood sugar)  Abnormal glucose tolerance tests  Progressive results  Water, electrolyte imbalance  Ketoacidosis  Coma 13Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    • 14. The Metabolic Pattern of Diabetes (p. 405)  Energy supply and control of blood glucose  Diabetes is especially related to metabolism of carbohydrate and fat  It is important to control blood glucose within normal levels of 70 to 110 mg/dl 14Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    • 15. Case Study  Mr. Jones is a 45-year-old black male. He is 25 lbs overweight. He also has a family history of diabetes. His most recent lab work reveals an elevated fasting blood sugar, elevated total cholesterol, and low HDL level. 15Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    • 16. Case Study (cont’d)  List Mr. Jones’ risk factors for type 2 diabetes. 16Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    • 17. Case Study (cont’d)  What other screening tools could be used for diabetes? 17Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    • 18. Case Study (cont’d)  What are some signs and symptoms that Mr. Jones may be experiencing? 18Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    • 19. The Metabolic Pattern of Diabetes (cont’d) (p. 405)  Sources of blood glucose  Dietary intake  Glycogen from liver and muscles  Uses of blood glucose  For immediate energy needs: glycolysis  Change to glycogen for storage: glycogenesis  Convert to fat for longer-term storage: lipogenesis 19Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    • 20. Pancreatic Hormone Control (p. 405)  Islets of Langerhans produce:  Insulin  Glucagon  Somatostatin 20Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    • 21. Islets of Langerhans (p. 407) 21Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    • 22. Insulin (p. 405)  Controls blood sugar  Helps transport glucose into cells  Helps change glucose to glycogen and store it in liver, muscles  Stimulates changes of glucose to fat for storage as body fat  Inhibits breakdown of tissue fat and protein  Promotes uptake of amino acids by skeletal muscles  Influences burning of glucose for energy 22Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    • 23. Glucagon (p. 407)  Acts in a manner opposite to insulin  Breaks down stored glycogen and fat  Raises blood glucose as needed to protect brain during sleep or fasting 23Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    • 24. Somatostatin (p. 407)  A “referee” for several other hormones  Inhibits secretion of insulin, glucagon, and other GI hormones  Also produced in other parts of the body (e.g., hypothalamus) 24Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    • 25. Abnormal Metabolism in Uncontrolled Diabetes (p. 407)  When insulin activity insufficient, imbalances occur in:  Glucose  Fat  Protein 25Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    • 26. Glucose (p. 407)  Glucose normally absorbed into pancreatic cells, triggering secretion of insulin  Glucose taken up into cells  Without insulin, cells starved for glucose 26Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    • 27. Fat (p. 407)  Without insulin, fat tissue formation decreases  Fat tissue breakdown increases  Intermediate products of fat breakdown, ketones, accumulate in body 27Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    • 28. Protein (p. 408)  Without insulin, protein also broken down to secure energy 28Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    • 29. Long-Term Complications (p. 408)  Retinopathy: leading cause of new cases of blindness age 20 to 74  Nephropathy: leading cause of end-stage renal disease  Neuropathy: nervous system damage in legs and feet  Heart disease  Dyslipidemia: Elevated triglyceride, decreased high-density lipoprotein cholesterol  Hypertension: A major comorbid condition 29Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    • 30. General Management of Diabetes (p. 409)  Early detection  Prevention of complications  Glucose tolerance test  Goals of care  Maintaining optimal nutrition  Avoiding symptoms  Preventing complications Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    • 31. General Management of Diabetes (cont’d) (p. 411)  Self-care skills  People with diabetes must treat themselves  Basic elements of diabetes management  Healthy diet  Physical activity  Ensure adequate insulin Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    • 32. Special Objectives During Pregnancy (p. 411)  Usually involves team of specialists  Careful monitoring of mother with diabetes  Preventing fetal damage Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    • 33. Lesson 20.2: Care for the Person with Diabetes Mellitus  Daily self-care skills enable a person with diabetes to remain healthy and reduce risks for complications.  Blood glucose monitoring is a critical practice for blood glucose control.  A personalized care plan balancing food intake, exercise, and insulin regulation is essential to successful diabetes management. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    • 34. Medical Nutrition Therapy for Individuals with Diabetes (p. 411)  Individuals with prediabetes  Promote healthy food choices  Increase physical activity  Achieve and maintain moderate weight loss Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    • 35. Medical Nutrition Therapy for Individuals with Diabetes (cont’d) (p. 411)  Individuals with diabetes  Blood glucose levels as safely as possible  Lipid and lipoprotein profile  Blood pressure levels  Prevent, or at least slow, the rate of chronic complications  Address individual nutrition needs  Maintain the pleasure of eating Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    • 36. Additional Considerations (p. 411)  Additional considerations  For youth with type 1 diabetes, youth with type 2 diabetes, pregnant and lactating women, and older adults with diabetes, to meet the nutrition needs of these unique times in the life cycle  Provide self-management training for safe conduct of exercise, including the prevention and treatment of hypoglycemia and diabetes treatment during acute illness Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    • 37. Total Energy Balance (p. 411)  Normal growth and weight management  Type 1 in childhood: use normal height/weight charts  Type 2 in adulthood: major goal is often weight reduction/control  Energy intake  Balances with needs for growth/development, physical activity, desirable lean weight  Negative balance if weight loss is goal Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    • 38. Nutrient Balance (p. 412)  Carbohydrate  Starch and sugar: Complex and simple carbohydrates  Glycemic index  Fiber  Sugar substitutes: Nutritive and nonnutritive  Glycemic index  Measure of a food’s ability to raise blood glucose level  Carbohydrates differ Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    • 39. Nutrient Balance (cont’d) (p. 412)  Fiber  Normal consumption encouraged  Sugar substitute sweeteners  Nutritive and nonnutritive allowed in moderation  Protein  About 10% to 35% of total energy  Fat  No more than 7% of kilocalories from saturated fat Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    • 40. Food Distribution (p. 414)  Eat even amounts of food at regular intervals  Maintain even blood glucose supply  Snacks may be needed  Adjust eating according to activity level and stress  Regulate glycemic response according to physical activity and exercise  Drug therapy Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    • 41. Daily Activity Schedule (p. 414)  Food distribution must be adjusted to activities  Especially important for children and adolescents  Stressful event can counteract insulin activity Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    • 42. Exercise (p. 414)  Recommendation: 150 min/week of moderate- intensity aerobic activity  Helps those with type 2 DM control blood glucose and prevent cardiovascular disease, other risks  For those using insulin, energy needs of exercise must be covered in food distribution plan Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    • 43. Drug Therapy (p. 415)  Affects food distribution  Patient must adjust diet, medications, exercise as needed Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    • 44. Diet Management (p. 415)  General planning according to type of diabetes  Develop plan to meet individual needs: living situation, background, food habits Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    • 45. Diet Management (cont’d) (p. 415)  Carbohydrate counting  Count carbohydrates for a meal  Inject appropriate amount of insulin to process glucose  Food exchange system  Organizes food into groups Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    • 46. Special Concerns (p. 416)  Special diet food items: usually not needed  Alcohol: occasional cautious use allowed  Hypoglycemia: prepare for possibility  Illness: adjust food and insulin accordingly  Travel: consult with dietitian first  Eating out: plan ahead and choose restaurants wisely  Stress: antagonistic to insulin Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    • 47. Diabetes Education Program (p. 419)  Goal: person-centered self-care  Patients taking more active role in their care  Diabetes requires daily survival skills  Diabetes Self-Management Education (DSME)  Support informed decision-making  Self-care behaviors  Problem-solving  Active collaboration with health care team Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    • 48. Necessary Skills (p. 419)  Healthy eating  Being active  Monitoring  Medications  Insulin  Oral hypoglycemic agents  Problem-solving  Health coping  Reducing risk Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    • 49. Case Study (cont’d)  The physician sends Mr. Jones for nutritional counseling.  What are your recommendations for him? Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    • 50. Resources (p. 422)  American Diabetes Association  American Dietetic Association  American Association of Diabetes Educators Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
    • 51. Staff Education (p. 422)  Success of diabetes education programs depends on sensitivity and training of staff  Continuing education essential Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

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