0
Postgraduate Diploma in Diabetes Education
(PDDE

Nutrition therapy: Dietary advice in
case of complications
lec. 3 nutrit...
Complications of Diabetes

Dr. Siham M.O. Gritly

2
Dr. Siham M.O. Gritly

3
Complications of Diabetes
• Complications of Diabetes In both types of
diabetes;
• glucose fails to gain entry into the ce...
Metabolic Patterns in Diabetes
• Diabetic subjects are constantly relying on protein
and fat for fuel.
• Proteins are degr...
• A lack of insulin action leads to mobilization
of fat from adipose tissue, β-oxidation and
formation of ketone bodies.
•...
the metabolic changes and acute complications
that can arise in Uncontrolled diabetes.
Adapted from; Ellie Whitney and Sha...
• Some cells produce glycoproteins by attaching
excess glucose to an amino acid in a protein;
the altered proteins cannot ...
• Infections occur due to poor circulation
coupled with glucose-rich blood and urine.
• People with diabetes must pay spec...
Metabolic Consequences of Untreated
Diabetes Type 1 diabetes
• In type 1, no insulin is available to allow any
glucose to ...
Metabolic Consequences of Untreated Diabetes
Type 1 diabetes

• No glucose enters the cells →
• Cells break down protein a...
•
•
•
•
•

Diabetic ketoacidosis manifested by:
Ketones in the breath (acetone breath)
Ketones in the blood (ketonemia)
Ke...
Ketone Body Metabolism
• Adipose TG’s provide the major storage form
of readily-available energy
• adipose triglycerids pr...
• acetoacetate, β-hydroxybutyrate, and acetone
(minor) released into blood since liver cannot
utilize them

• Ketones are ...
• When the rate of synthesis of ketone bodies
exceeds the rate of utilization, their
concentration in blood increases;

• ...
• ketonemia. This is followed by ketonuria –
excretion of ketone bodies in urine.
• The ketonemia and ketonuria is commonl...
Metabolic Consequences of Untreated Diabetes
Type 11 diabetes
• In type 2 diabetes, some glucose enters the
cells.
• In th...
Metabolic Consequences of Untreated Diabetes
Type 11 diabetes

• Some glucose enters the cells, but slowly →
• Hunger →
• ...
What is Diabetic nephropathy
• Diabetic nephropathy is the impact of diabetes on
the kidneys tissues, lead to loss of prot...
• Symptoms
• edema: swelling, usually around the eyes in the
mornings;
• later, general body swelling may result, such as
...
Diabetic nephropathy Kidney failure aggravated by
glomerulosclerosis leads to fluid filtration deficits
and other disorder...
The earliest detectable change in the course of diabetic
nephropathy is a thickening in the glomerulus. At this
stage, the...
During diabetic nephropathy the kidney becomes damaged and
more protein than normal collects in the urine. As the disease
...
Dietary Management of Diabetic
Nephropathy
• Reduce protein to 0.8-1 g/kg/day in individuals
with microalbunimuria.
• Some...
What is diabetic neuropathy?
Diseases of the Nerves
• Neuropathy is damage to nerves, and diabetic
neuropathy is damage to...
•
•
•
•

Different types of diabetic neuropathy include
Peripheral neuropathy,
focal neuropathy,
Autonomic neuropathy caus...
Peripheral neuropathy most commonly causes
pain, burning, tingling, and numbness of the
feet and lower legs.
diabetic neur...
Adapted from; Ellie Whitney and Sharon Rady Rolfes; Under standing
Nutrition, Twelfth Edition. 2011, 2008 Wadsworth, Cenga...
dietary management of diabetic
neuropathy
• control of blood sugar levels is the best way to
prevent diabetic neuropathy a...
Diabetes and Celiac Disease
• Coeliac Disease is a condition where the lining
of the small intestine is damaged due to
sen...
Coeliac Disease and diabetes may occur together
and is more common in people with type 1 than
type 2 diabetes.

Celiac dis...
the lining of the small intestine is damaged due
to sensitivity to a protein in food gluten.
Adapted from; Ragnar Hanas, M...
The mucosa seen through a microscope
Ref. Ragnar Hanas, MD, PhD
Dept. of Pediatrics, Uddevalla, Sweden

Celiac disease

No...
Onset of celiac disease in first year of life
Symptoms associated

with Celiac Disease
Chronic diarrhoea
Failure to thrive...
Symptoms associated with Celiac Disease
• Symptoms vary from person to person and range
from mild to severe
• Malabsorptio...
dietary management of diabetic Celiac
Disease
• A gluten-free diet is currently the only known
treatment for Coeliac Disea...
• Beans and legumes can be used to increase fiber
content of the diet
• Foods that are low in saturated fat
• Plenty of fr...
•
•
•
•
•
•

avoid grains such as
wheat,
rye,
oats,
barley.
processed foods with ingredients such as wheaten corn
flour,
•...
Diabetes and Cystic fibrosis
• Cystic fibrosis a disease that cause damage
to the pancreas (pancreatic insufficiency)
• If...
• Common symptoms,
• increased thirst
• increased urination, are caused by high blood
sugar levels (hyperglycemia).
• fati...
• Weight loss can occur rapidly because of low
insulin levels and high glucose levels
• high-energy diet with extra calori...
Special situations
Inter-current illness
• During acute intercurrent illness, advise on;
• adequate hydration/nutrition es...
• Hospital care
• allow persons with diabetes to make their own
food choices.

• Hospital dieticians should ensure menus h...
Catabolic illness
• The energy needs of most hospitalised persons can be
met by providing 25-35 kcal/kg body weight.
•
• I...
Palliative care
• A WHO statement explained palliative care as
"an approach that improves the quality of life
of patients ...
• the term "palliative care" may refer to any care
that alleviates symptoms, whether or not there is
hope of a cure by oth...
• integrates the psychological and spiritual
aspects of patient care;
• offers a support system to help patients live as
a...
• Palliative care is provided by a team of
doctors, nurses, and other specialists who
work together with a patient's other...
References
• American Diabetes Association (2002). Clinical Practice
Recommendations:2002. Diabetes Care 25 (suppl. 1):S64...
• American Diabetes Association. Standards of medical
care in diabetes--2011. Diabetes Care. 2011 Jan;34
Suppl 1:S11-61
• ...
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Lec 3 nutrition therapy that apply to specific situations

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  • Adapted from; Ellie Whitney and Sharon RadyRolfes; Under standing Nutrition, Twelfth Edition. 2011, 2008 Wadsworth, Cengage Learning
  • Adapted from; Ellie Whitney and Sharon RadyRolfes; Under standing Nutrition, Twelfth Edition. 2011, 2008 Wadsworth, Cengage Learning
  • Adapted from; Ellie Whitney and Sharon RadyRolfes; Under standing Nutrition, Twelfth Edition. 2011, 2008 Wadsworth, Cengage Learning
  • Adapted from; Ellie Whitney and Sharon RadyRolfes; Under standing Nutrition, Twelfth Edition. 2011, 2008 Wadsworth, Cengage Learning
  • Adapted from; Ellie Whitney and Sharon RadyRolfes; Under standing Nutrition, Twelfth Edition. 2011, 2008 Wadsworth, Cengage Learning
  • Adapted from; Ellie Whitney and Sharon RadyRolfes; Under standing Nutrition, Twelfth Edition. 2011, 2008 Wadsworth, Cengage Learning
  • Ragnar Hanas, MD, PhD Dept. of Pediatrics, Uddevalla, Sweden
  • Transcript of "Lec 3 nutrition therapy that apply to specific situations"

    1. 1. Postgraduate Diploma in Diabetes Education (PDDE Nutrition therapy: Dietary advice in case of complications lec. 3 nutrition therapy that apply to specific situations Prepared by; Dr. Siham M.O. Gritly 1
    2. 2. Complications of Diabetes Dr. Siham M.O. Gritly 2
    3. 3. Dr. Siham M.O. Gritly 3
    4. 4. Complications of Diabetes • Complications of Diabetes In both types of diabetes; • glucose fails to gain entry into the cells • and consequently accumulates in the blood. • These two problems lead to both acute and chronic complications. Dr. Siham M.O. Gritly 4
    5. 5. Metabolic Patterns in Diabetes • Diabetic subjects are constantly relying on protein and fat for fuel. • Proteins are degraded for gluconeogenesis. • Glycolysis is inhibited and gluconeogenesis is stimulated. • glucose (and water) are removed in urine. The diabetic subject suffer from acute hunger and thirst Dr. Siham M.O. Gritly 5
    6. 6. • A lack of insulin action leads to mobilization of fat from adipose tissue, β-oxidation and formation of ketone bodies. • In general metabolism shift from carbohydrate usage to fat usage. • Excessive buildup of ketone bodies leads to lowering of the pH. • When the kidneys can’t keep up with acid-base homeostasis, ketoacidosis can be fatal Dr. Siham M.O. Gritly 6
    7. 7. the metabolic changes and acute complications that can arise in Uncontrolled diabetes. Adapted from; Ellie Whitney and Sharon Rady Rolfes; Under standing Nutrition, Twelfth Edition. 2011, 2008 Wadsworth, Cengage Learning • The metabolic consequences of type 1 diabetes differ from those of type 2. • Chronically elevated blood glucose alters glucose metabolism in every cell of the body. • Some cells begin to convert excess glucose to sugar alcohols, for example, causing toxicity and cell distention; • distended cells in the lenses of the eyes, for example, cause dim vision. Dr. Siham M.O. Gritly 7
    8. 8. • Some cells produce glycoproteins by attaching excess glucose to an amino acid in a protein; the altered proteins cannot function normally, • The structures of the blood vessels and nerves become damaged, leading to loss of circulation and nerve function. Dr. Siham M.O. Gritly 8
    9. 9. • Infections occur due to poor circulation coupled with glucose-rich blood and urine. • People with diabetes must pay special attention to hygiene and keep alert for early signs of infection. Dr. Siham M.O. Gritly 9
    10. 10. Metabolic Consequences of Untreated Diabetes Type 1 diabetes • In type 1, no insulin is available to allow any glucose to enter the cells. • When glucose cannot enter the cells, a metabolic changes quickly follows. Dr. Siham M.O. Gritly 10
    11. 11. Metabolic Consequences of Untreated Diabetes Type 1 diabetes • No glucose enters the cells → • Cells break down protein and fat which lead to → • Ketones produced for energy (ketosis) or → • Weight loss that lead to → • Excessive eating (polyphagia) Dr. Siham M.O. Gritly 11
    12. 12. • • • • • Diabetic ketoacidosis manifested by: Ketones in the breath (acetone breath) Ketones in the blood (ketonemia) Ketones in the urine (ketonuria) This result in Diabetic coma Dr. Siham M.O. Gritly 12
    13. 13. Ketone Body Metabolism • Adipose TG’s provide the major storage form of readily-available energy • adipose triglycerids provides FFA’s to liver which makes ketones that are necessary for prolonged starvation Dr. Siham M.O. Gritly 13
    14. 14. • acetoacetate, β-hydroxybutyrate, and acetone (minor) released into blood since liver cannot utilize them • Ketones are used by skeletal, brain and cardiac muscle, the renal cortex, and other tissues Dr. Siham M.O. Gritly 14
    15. 15. • When the rate of synthesis of ketone bodies exceeds the rate of utilization, their concentration in blood increases; • acetoacetic acid and beta-hydroxybutyric acid are acidic, and, if levels of these ketone bodies are too high, the pH of the blood drops, resulting in ketoacidosis Dr. Siham M.O. Gritly 15
    16. 16. • ketonemia. This is followed by ketonuria – excretion of ketone bodies in urine. • The ketonemia and ketonuria is commonly referred as ketosis. • Smell of acetone in breath is a common feature in ketosis Dr. Siham M.O. Gritly 16
    17. 17. Metabolic Consequences of Untreated Diabetes Type 11 diabetes • In type 2 diabetes, some glucose enters the cells. • In this case the body does not shift into the metabolism of fasting (losing weight and producing ketones). Dr. Siham M.O. Gritly 17
    18. 18. Metabolic Consequences of Untreated Diabetes Type 11 diabetes • Some glucose enters the cells, but slowly → • Hunger → • Excessive eating (polyphagia) → • Weight gain Dr. Siham M.O. Gritly 18
    19. 19. What is Diabetic nephropathy • Diabetic nephropathy is the impact of diabetes on the kidneys tissues, lead to loss of protein in the urine, and eventually chronic kidney disease requiring dialysis . • Diabetic nephropathy is a clinical syndrome characterized by the following: Persistent albuminuria (>300 mg/d or >200 μg/min) that is confirmed on at least 2 occasions 3-6 months apart Progressive decline in the glomerular filtration rate (GFR) Elevated arterial blood pressure Dr. Siham M.O. Gritly 19
    20. 20. • Symptoms • edema: swelling, usually around the eyes in the mornings; • later, general body swelling may result, such as swelling of the legs • foamy appearance of the urine (caused by the proteinuria) • unintentional weight gain (from fluid accumulation) • anorexia (poor appetite) Dr. Siham M.O. Gritly 20
    21. 21. Diabetic nephropathy Kidney failure aggravated by glomerulosclerosis leads to fluid filtration deficits and other disorders of kidney function Dr. Siham M.O. Gritly 21
    22. 22. The earliest detectable change in the course of diabetic nephropathy is a thickening in the glomerulus. At this stage, the kidney may leak more serum albumin (plasma protein) than normal in the urine ( albuminuria),This stage is called microalbuminuria. Dr. Siham M.O. Gritly 22
    23. 23. During diabetic nephropathy the kidney becomes damaged and more protein than normal collects in the urine. As the disease progresses, more of the kidney is destroyed. Over time, the kidney's ability to function starts to decline, which may eventually lead to chronic kidney failure. Dr. Siham M.O. Gritly 23
    24. 24. Dietary Management of Diabetic Nephropathy • Reduce protein to 0.8-1 g/kg/day in individuals with microalbunimuria. • Some researchers suggested that In diabetic nephropathy, protein restriction may vary between 0.4 – 0.6 g per kilogram Dr. Siham M.O. Gritly 24
    25. 25. What is diabetic neuropathy? Diseases of the Nerves • Neuropathy is damage to nerves, and diabetic neuropathy is damage to nerves that occurs as a result of diabetes. • Diabetic neuropathy is the most common complication of diabetes. • Diabetic neuropathy can affect different parts of the body, and symptoms can range from mild to severe. Dr. Siham M.O. Gritly 25
    26. 26. • • • • Different types of diabetic neuropathy include Peripheral neuropathy, focal neuropathy, Autonomic neuropathy causes symptoms related to dysfunction of an organ system, such as urinary incontinence diarrhea, constipation • and proximal neuropathy. proximal neuropathy characterized by painful muscle wasting and weakness. Dr. Siham M.O. Gritly 26
    27. 27. Peripheral neuropathy most commonly causes pain, burning, tingling, and numbness of the feet and lower legs. diabetic neuropathy together with vascular disease in the legs, contributes to the risk of diabetic-related foot problems (such as diabetic-food ulcers) that can be difficult to treat and occasionally require amputation Dr. Siham M.O. Gritly 27
    28. 28. Adapted from; Ellie Whitney and Sharon Rady Rolfes; Under standing Nutrition, Twelfth Edition. 2011, 2008 Wadsworth, Cengage Learning Nerve tissues may also deteriorate with diabetes, expressed at first as a painful prickling sensation, often in the arms and legs. Later, the person loses sensation in the hands and feet. Injuries to these areas may go unnoticed, and infections can progress rapidly. With loss of both circulation and nerve function, undetected injury and infection may lead to death of tissue (gangrene). gangrene is the death of tissue, usually due to deficient blood supply, Dr. Siham M.O. Gritly 28
    29. 29. dietary management of diabetic neuropathy • control of blood sugar levels is the best way to prevent diabetic neuropathy and other complications of diabetes Dr. Siham M.O. Gritly 29
    30. 30. Diabetes and Celiac Disease • Coeliac Disease is a condition where the lining of the small intestine is damaged due to sensitivity to a protein in food called gluten. • Gluten is a protein found in grains such as wheat, rye, oats, barley. also be found in processed foods with ingredients such as wheaten corn flour, wheat starch, malt, malt extract, malt dextrin and the thickeners Dr. Siham M.O. Gritly 30
    31. 31. Coeliac Disease and diabetes may occur together and is more common in people with type 1 than type 2 diabetes. Celiac disease • villous atrophy • malnutrition Dr. Siham M.O. Gritly 31
    32. 32. the lining of the small intestine is damaged due to sensitivity to a protein in food gluten. Adapted from; Ragnar Hanas, MD, PhD Dept. of Pediatrics, Uddevalla, Sweden When the villi are destroyed by celiac antibodies the absorption area decrease A healthy mucosa with villi The purpose of the villi is to increase the absorption area of the intestinal mucosa Dr. Siham M.O. Gritly 32
    33. 33. The mucosa seen through a microscope Ref. Ragnar Hanas, MD, PhD Dept. of Pediatrics, Uddevalla, Sweden Celiac disease Normal villi Dr. Siham M.O. Gritly 33
    34. 34. Onset of celiac disease in first year of life Symptoms associated with Celiac Disease Chronic diarrhoea Failure to thrive Abdominal distension growth failure in children with diabetes may indicate the presence of coeliac disease Dr. Siham M.O. Gritly 34
    35. 35. Symptoms associated with Celiac Disease • Symptoms vary from person to person and range from mild to severe • Malabsorption commonly occurs in people with undiagnosed coeliac disease and Type 1 DM. • hypoglycaemia • Diarrhoea • Streatorrhoea (floating, fatty stools) • Loss of weight • Abdominal bloating or distension • Flatulence Dr. Siham M.O. Gritly 35
    36. 36. dietary management of diabetic Celiac Disease • A gluten-free diet is currently the only known treatment for Coeliac Disease. • Gluten-free foods include corn, rice, sago , tapioca, buckwheat , potato, soy, arrowroot, fresh fruit, vegetables, meat (except most processed meats), poultry, fish and most dairy foods Dr. Siham M.O. Gritly 36
    37. 37. • Beans and legumes can be used to increase fiber content of the diet • Foods that are low in saturated fat • Plenty of fruit and vegetables. • Calcium supplements to be given to reduce risk of osteoporosis if dietary intake is < 1500 mg/day. Dr. Siham M.O. Gritly 37
    38. 38. • • • • • • avoid grains such as wheat, rye, oats, barley. processed foods with ingredients such as wheaten corn flour, • wheat starch, • malt, • malt extract, malt dextrin and the thickeners Dr. Siham M.O. Gritly 38
    39. 39. Diabetes and Cystic fibrosis • Cystic fibrosis a disease that cause damage to the pancreas (pancreatic insufficiency) • If enough beta cells are damaged, the body can’t make enough insulin to metabolize food • Decreased amounts of insulin lead to raise the blood glucose levels Dr. Siham M.O. Gritly 39
    40. 40. • Common symptoms, • increased thirst • increased urination, are caused by high blood sugar levels (hyperglycemia). • fatigue, • weight loss • and unexplained decline in lung function Dr. Siham M.O. Gritly 40
    41. 41. • Weight loss can occur rapidly because of low insulin levels and high glucose levels • high-energy diet with extra calories from fat and no restriction on carbohydrate is required. • Keeping blood glucose levels at a normal or nearnormal level Insulin is primary treatment Dr. Siham M.O. Gritly 41
    42. 42. Special situations Inter-current illness • During acute intercurrent illness, advise on; • adequate hydration/nutrition especially easily digested foods/drinks, e.g. soup, yoghurt, jelly, fruit juice. • Increase fluids especially if there is fever, vomiting, or diarrhoea. • Commercial oral rehydration salts can be used or even tomato juice or broth. • Continue medication when ill Dr. Siham M.O. Gritly 42
    43. 43. • Hospital care • allow persons with diabetes to make their own food choices. • Hospital dieticians should ensure menus have appropriate or healthy food choices. • All wards should have food and drink for oral treatment of hypoglycaemia. Dr. Siham M.O. Gritly 43
    44. 44. Catabolic illness • The energy needs of most hospitalised persons can be met by providing 25-35 kcal/kg body weight. • • In catabolic illness, at least 1.0 g/kg body weight up to 1.5 g/kg body weight in more stressed persons. • • Avoid overfeeding to prevent hyperglycaemia, hypertriglyceridaemia and hypertonic dehydration. • Correct mineral/vitamin deficiencies before enteral or parenteral feeding is begun when indicated Dr. Siham M.O. Gritly 44
    45. 45. Palliative care • A WHO statement explained palliative care as "an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable (perfect) assessment and treatment of pain and other problems, physical, psychosocial and spiritual." Dr. Siham M.O. Gritly 45
    46. 46. • the term "palliative care" may refer to any care that alleviates symptoms, whether or not there is hope of a cure by other means; thus, palliative treatments may be used to alleviate the side effects of curative treatments, such as; • relieving the nausea associated with chemotherapy • affirms life and regards dying as a normal process; • intends neither to hasten nor to postpone death Dr. Siham M.O. Gritly 46
    47. 47. • integrates the psychological and spiritual aspects of patient care; • offers a support system to help patients live as actively as possible; • offers a support system to help the family cope; • uses a team approach to address the needs of patients and their families; • will enhance quality of life; Dr. Siham M.O. Gritly 47
    48. 48. • Palliative care is provided by a team of doctors, nurses, and other specialists who work together with a patient's other doctors to provide an extra layer of support. It is appropriate at any age and at any stage in a serious illness and can be provided along with curative treatment. Dr. Siham M.O. Gritly 48
    49. 49. References • American Diabetes Association (2002). Clinical Practice Recommendations:2002. Diabetes Care 25 (suppl. 1):S64-S68. • Sareen Gropper, Jack Smith and James Groff, Advanced Nutrition and Human Metabolism, fifth ed. WADSWORTH • Melvin H Williams 2010; Nutrition for Health, Fitness and Sport. 9th ed, McGraw Hill • Heymsfield, SB.; Baumgartner N.; Richard and Sheau-Fang P. 1999. Modern Nutrition in Health and Disease; Shils E Maurice, Olson A. James, Shike Moshe and Ross A. Catharine eds. 9th edition • Guyton, C. Arthur. 1985. Textbook of Medical Physiology. 6th edition, W.B. Company Dr. Siham M.O. Gritly 49
    50. 50. • American Diabetes Association. Standards of medical care in diabetes--2011. Diabetes Care. 2011 Jan;34 Suppl 1:S11-61 • American Diabetes Association. Nutrition recommendations and interventions for diabetes: a position statement of the American Diabetes Association. Diabetes Care. 2008;31:S61-S78. • American Diabetes Association. Carbohydrate counting. Available at http://www.diabetes.org/foodand-fitness/food/planning-meals/carbcounting. Accessed December 8, 2012. Dr. Siham M.O. Gritly 50
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