NHHC chapter 20 outline

1. Chapter 20 – Nutrition and Diabetes Mellitus
Chapter Outline Instructor Resources
I. Overview of Diabetes Mellitus
A. Introduction
1. Incidence of diabetes mellitus is steadily increasing
2. Metabolic disorders characterized by:
a. Elevated blood glucose
b. Disordered insulin metabolism
3. May have:
a. Impaired insulin secretion
b. Cells that do not respond to insulin normally
4. Results in hyperglycemia
B. Symptoms of Diabetes Mellitus
1. Classic symptoms
a. Glycosuria
b. Polyuria
c. Polydipsia
d. Polyphagia
2. Other consequences
a. Blurred vision
b. Increased infections
c. Constant fatigue
C. Diagnosis of Diabetes Mellitus
1. Oral glucose tolerancetest
2. HbA1c
3. Random plasma glucose 200 mg/dL or > & classic symptoms
4. Fastingglucose level 126 mg/dL or >
5. Plasma glucose 2 hours after a 75-gglucose load = 200 mg/dL or >
6. HbA1c ≥6.5%
7. Prediabetes
a. Fastingglucose level 100-125 mg/dL
b. Plasma glucose 2 hours after a 75-gglucose load = 140-199 mg/dL
c. HbA1c = 5.7-6.4%
D. Types of Diabetes Mellitus
1. Type 1 Diabetes
a. 5-10% of cases
b. Autoimmune destruction of pancreatic beta cells
c. Insulin therapy needed
d. May be genetically susceptibleand at riskof developing other autoimmunediseases
e. Usually occurs in childhood or adolescence
f. Ketoacidosis may be the first sign
2. Type 2 Diabetes
a. 90-95% of cases
b. Often asymptomatic
c. Some insulin is produced

2. d. Insulin resistance& relativeinsulin deficiency
e. Beta cells get exhausted
f. Risk increased with:
1. Obesity
2. Age
3. Physical inactivity
4. Genetics (family history)
3. Type 2 Diabetes in Children and Adolescents - Prevalence is increasingin children and
correlates with therisein childhood obesity
E. Prevention of Type 2 Diabetes Mellitus
1. Weight management
2. Active lifestyle
3. Dietary modifications
4. Regular monitoring
F. Acute Complications of Diabetes Mellitus
1. Overview of acute complications
a. Disturbances in energy metabolism
b. Fluid & electrolyteimbalances
c. Hyper- & hypoglycemia
2. Diabetic Ketoacidosis in Type 1 Diabetes
a. Fatty acids and amino acids fuel the liver to produce ketone bodies and glucose
b. Ketonuria
c. Ketosis
d. Acidosis
e. Hyperglycemia
f. Acetone breath
g. May see fatigue, lethargy,nausea or vomiting
h. Diabetic coma
i. Treatment:
1. Insulin
2. IV fluid and electrolytereplacement
3. Bicarbonatetotreat acidosis
j. Causes: Missed insulin, illness, infection, alcohol abuse, other physiological stressors
k. Higher mortality rate
3. Hyperosmolar Hyperglycemic Syndrome in Type 2 Diabetes
a. Fluid & electrolytelosses
b. BG >600-2000 mg/dL
c. Blood plasma becomes hyperosmolar
d. Associated neurological abnormalities
e. 10% lapse intocoma
f. Condition evolves slowly
g. Mortality rateas high as 20%
4. Hypoglycemia = low blood glucose
a. Inappropriatemanagement
b. Excessive insulin or antidiabetic drugs
c. Prolonged exercise
d. Skipped/delayed or inadequate meals
e. Alcohol without food

3. f. Most frequent cause of coma in insulin-treated patients
g. Symptoms
1. Sweating
2. Heart palpitations
3. Shakiness
4. Hunger
5. Weakness
6. Dizziness
7. Irritability
G. Chronic Complications of Diabetes Mellitus
1. Overview
a. Formation of AGEs
b. AGEs cause damage to cells and blood vessels
c. Sorbitol production increases oxidativestress
2. Macrovascular Complications
a. Accelerated atherosclerosis
b. Peripheral vascular disease
c. Foot ulcers
3. Microvascular Complications
a. Diabetic retinopathy
b. Diabetic nephropathy
4. Diabetic Neuropathy
a. Pain & burning
b. Numbness & tingling
c. Cramping
d. Loss of sensation
e. Sweatingabnormalities
f. Disturbances in bladder and bowel function
g. Sexual dysfunction
h. Constipation
i. Delayed stomach emptying= gastroparesis
II. Treatment of Diabetes Mellitus
A. Overview
1. Diabetes mellitus is a chronic and progressive illness
2. Balance:
a. Meal planning
b. Medication timing
c. Physical exercise
3. Type 1 - Requires insulin therapy
4. Type 2
a. Diet therapy
b. Exercise
c. Oral medications or insulin
5. Requires education in self-management of disease
B. Treatment Goals
1. Desirable blood glucose levels
2. Prevent or reduce risk of complications

4. 3. Intensive diabetes therapy
4. Healthy blood lipid concentrations
5. Control blood pressure
6. Manage weight
7. CDE teaches methods of treatment
C. Evaluating Diabetes Treatment
1. Daily monitoring
a. Self-monitoringof blood glucose testing - Type 1: 3 or more times/day
b. Continuous glucose monitoring
2. Long-Term Glycemic Control
a. Glycated hemoglobin (HbA1c)
1. Measures glycemic control in past 2-3 months
2. Goal = <7%
b. Fructosaminetest
1. Measures glycemic control in the preceding 2-week period
2. Used to evaluaterecent adjustments in diabetes treatment and glycemic control in
pregnancy
3. Monitoring for Long-Term Complications
a. Routine blood pressurechecks
b. Lipid screening
c. Urinary protein screening
4. Ketone Testing
D. Nutrition Therapy:Dietary Recommendations
1. Macronutrient Intakes
a. Macronutrient distribution depends on food preferences & metabolic factors
b. Day-to-day consistency in carbohydrateintakeis associated with better glycemic control
2. Total CarbohydrateIntake - Should not restrict carbohydrateintaketo <130 g/d
3. CarbohydrateSources - Glycemic effects influenced by typeof carbohydrate,fiber content,
preparation method,other foods included, & individual tolerance
4. Sugars - Minimize foods & drink with added sugars
a. Moderate consumption not shown to adversely affect glycemic control
b. Sugar must be counted toward daily carbohydrateallowance
c. Fructose may adversely affect blood lipid levels
d. Sugar alcohols and artificial sweeteners
5. Fiber - Same as general population
6. Dietary Fat - Same as general population unless LDL increases
7. Protein - 15-20% of kcalories
8. Alcohol Use in Diabetes - Should be with food
9. Micronutrients - Same as general population
10. Body Weight in Type 2 Diabetes
a. Overweight or obese worsens insulin resistance
b. Weight loss is recommended for overweight or obese individuals
c. Weight loss is most beneficial early in the course of diabetes
E. Nutrition Therapy:Meal-PlanningStrategies
1. CarbohydrateCounting
a. Simpler & more flexible than other methods
b. Person given a daily carbohydrateallowance
c. Divided intopattern of meals & snacks

5. d. How to Use CarbohydrateCountingin Clinical Practice
e. Advanced level allows more flexibility & is best suited for patients using intensive
insulin therapy
2. Exchange Lists for Meal Planning
a. More complex & difficult to learn
b. Sorts foods according to their proportions of CHO, fat, & protein
c. Each food has similar macronutrient &energy content
F. Insulin Therapy
1. Indications
a. For people that can’t produce enough insulin
b. Type 1 diabetes
c. Some persons with type2
2. Insulin Preparations - differ by:
a. Onset of activity
b. Timing of peak activity
c. Duration of effects
3. Insulin Delivery
a. Subcutaneous injection with syringes
b. Insulin pens
c. Insulin pumps
d. At least 3 or more daily injections required for good glycemic control without pump
e. Carbohydrate-to-insulin ratio
4. Insulin Regimen for Type 1 Diabetes
a. Multiple daily injections
b. Several types of insulin
c. Insulin pump
5. Insulin Regimen for Type 2 Diabetes
a. 30% of persons need insulin
b. Insulin alone
c. Insulin with oral agents
6. Insulin Therapy and Hypoglycemia
a. Most common complication
b. Need immediate intake of glucose or CHO food
c. 15-20 grams
d. Resolves in about 15 minutes with CHO ingestion
e. 15 grams CHO =
1. 4 glucose tablets
2. 4 tsp tablesugar
3. 4 tsp maple syrup
4. ½ cup canned orange juice
5. 15 small jelly beans
7. Insulin Therapy and Weight Gain - sometimes an unintentional side effect
a. Associated especially with intensiveinsulin therapy
b. Prevention:reduce ratioof basal insulin tomealtime insulin;improve CHO counting
skills to properly judge mealtimeinsulin requirements
8. FastingHyperglycemia - 3 possible causes:
a. Waninginsulin action
b. Dawn phenomenon

6. c. Rebound hyperglycemia,a.k.a. Somogyi effect
G. Antidiabetic Drugs
1. Stimulateinsulin secretion
2. Suppress glucagon secretion
3. Increase insulin sensitivity
4. Improve glucose use by tissues
5. Reduce liver glucose production
6. Delay stomach emptying
7. Delay CHO digestion & absorption
8. Treatment may be monotherapy or combination therapy
H. Physical Activity and Diabetes Management
1. Medical Evaluation before Exercise
2. MaintainingGlycemic Control - Don’t inject insulin right before exercise & check BG before
& after to avoid hypoglycemia
I. Sick-Day Management
1. Type 1 diabetes - Illness increases ketoacidosis risk
2. Recommendations
a. Frequent blood glucose testing
b. Continue use of medication(s)
c. Select easy-to-managefoods and beverages
d. Consume adequate amounts of liquids throughout the day
III. Diabetes Management in Pregnancy
A. Introduction
1. Pregnancy increases insulin resistance& need for insulin
2. Glycemic control more difficult
3. Uncontrolled diabetes
a. Miscarriages
b. Birth defects
c. Fetal deaths
4. Increased risk for:
a. Delivery of large babies (macrosomia)
b. May need C-section
B. Pregnancy in Type 1 or Type 2 Diabetes
1. Need glycemic control
2. At conception & during 1st trimester toreduce risks of birth defects
3. 2nd & 3rd trimesters tominimizerisks of large babies & infant mortality
C. Gestational Diabetes
1. Risk factors:
a. Family history of diabetes
b. Obesity
c. Certain ethnic groups
d. Delivered babies weighingover 9 pounds
2. May need to restrict carbohydrates to40-45% total kcalories
3. Limit carbohydrates in themorningto 30 grams
4. Space carbohydrates throughout theday
5. Regular aerobic activity
6. May need insulin

7. IV. Nutrition in Practice- The Metabolic Syndrome
A. Introduction
1. Metabolic syndrome(MS) = cluster of metabolic abnormalities
2. MS increases riskfor CVD and type 2 diabetes
B. How is the metabolic syndromediagnosed, and how common is it in the U.S.?
1. MS is diagnosed when an individual has 3 of the following:
a. Hyperglycemia
b. Abdominal obesity
c. Hypertriglyceridemia
d. Reduced HDL
e. Hypertension
2. Risk varies among ethnic groups
C. What causes the metabolic syndrome?
1. Usually both genetic and environmental factors
2. Obesity
3. Abdominal obesity
D. How does obesity lead to insulin resistance?
1. Exact mechanism is unclear
2. High cellular fat content may alter cellular response to insulin
E. Can obesity cause other problems related to the metabolic syndrome?
1. Blood lipid abnormalities
2. Raise in blood pressure
F. How does themetabolic syndromecontributetocardiovascular diseaserisk?
1. Associated disorders areall independent risk factors for CVD
2. Often associated with blood vessel dysfunction & the tendency to form blood clots
G. What is the usual treatment for the metabolic syndrome? - Dietary & lifestylechanges: primarily
to promote weight loss
H. What dietary strategies,other than weight loss, are suggested for people with the metabolic
syndrome?
1. Reduce added sugar & refined grains
2. Increase servings of high-fiber foods
3. Include fish in diet weekly
4. Reduce sodium & increasefruits, vegetables,& low-fat milk products
5. Choose a diet low in saturated and trans fats & cholesterol
I. Why is physical activity recommended for people with themetabolic syndrome?
1. Weight management
2. May improve:
a. Blood lipid concentrations
b. Blood pressure
c. Insulin resistance
J. What types of medications areused to treat themetabolic syndrome? - If dietary and lifestyle
changes are unsuccessful, may need medication to correct hypertriglyceridemia and
hypertension