Diabetes, nutrition, obesity

3 CM of DM

Polyuria, polyphagia (excessive hunger), polydipsia

5 metabolic syndrome components - need 3/5 to be at risk for DM2

1. Increased glucose levels

2. abdominal obesity

3. high BP

4. high triglycerides

5. low HDL

prediabetes signs

OGTT 140-199 mg/dL

Fasting glucose 100-125

or asymptomatic

diagnostic studies of Diabetes

1. A1C above 6.5%

2. FPG above 126 mg/dL

3. OGTT (glucose last 2 hours) above 200 mg/dL

4. random plasma glucose above 200 mg/dL

Repeat criteria 1-3 occasions

bolus vs. Basal

Bolus - rapid or short acting given before meals

Basal - intermediate or long acting given 1-2 per day

Somogyi and dawn phenomenom

S: High insulin dose causes late night hypoglycemia, counteracting hormones may cause rebound hyperglycemia

D: Morning hyperglycemia from insulin where off or counteracting hormones

moderate weight loss ______-_____ % improves insulin sensetivity

5-7%

alcohol on diabetes

inhibits gluconeogenesis by liver, causing severe hypoglycemia

When to test BS

Before meals, two hours after first bite, when hypoglycemia is expected, every 4 hours during illness, before and after exercise

DKA

profound insulin deficiency

hyperglycemia, ketosis, acidosis, dehydration

Patho: Body burns fat as fuel, fat metabolism has a by-product of ketones - which alter pH, they also get excreted in urine

CM: dehydration, lethergy, weakness, dry, GI, kussmaul respirations

Chronic complications of diabetes

angiopathy - damage to BV

Macro and microvascular complications (disease or thickening)

a. Neuropathy, retinopathy, nephropathy

Which can entail loss of feeling in extremities > PAD

Drugs for DM

Metformin: reduce glucose production by liver

sulfonylureas: increase insulin production from pancreas

Meglitinides: Increase insulin production from pancreas

Alpha glucosidase inhibitor: Slow down absorption of carbohydrates in small intestine

thiazolidinediones: Improves insulin sensitivity and transport

DPP4: augment incretin hormone - increase insulin synthesis and release and decrease liver glucose

SGLT2: block reabsorption of glucose by kidney

DOpamine receptor agonist: Improves glucose levels by increasing dopamine receptor activity

GLP 1: increase insulin synthesis and release, inhibit glucagon, slow emptying, increase satiety

amylin: slow gastric emptying, reduce postprandial glucagon, increase satiety

Calorie calculation

20-35 calories per kilogram of body weight per day

30-35 per kg for injured or with illness

carbohydrates

primary source of energy

4 kcals/g

compose 45-65% of daily caloric needs

14g fiber/1000 cals

Fats

Major source of energy

9 kcals/g

20-35% daily caloric intake

protein

required for tissue growth, repair, and maintenece

4 cal/g

10-35% daily caloric need

vitamins

organic compounds required in small amounts for normal metabolism and enzyme reactions

mineral salts

magnesium, iron, calcium, necessary to build and repair tissue

Starvation process

Body starts by using us carbohydrates from liver and muscles

within 5-9 days, fat stores are mobilized for energy

after 4-6 weeks body protein is used

How do we assess malnutrition

Albumin and prealbumin - plasma oncotic pressure decreases so body fluids shift to interstitial space - albumin leaks to interstitial space

skin is dry and wrinkly, Na+ K+ pump fails - deficiency in calories and proteins

liver loses the most mass and becomes infiltrated with fat

refeeding syndrome

bodys response to switch from starvation to fed state

Hypophosphatemia is the hallmark - need phosphorus for ATP energy

also causes hyperglycemia, fluid retention, hypokalemia, and hypomagnesemia

enteral +indications + contraindications

E: catheter/tube directly into GI tract (stomach, duodenum or jejunum)

Indications: anorexia, orofacial fractures, head/neck cancer, neuro problems, burns, critical illness, chemo, radiation

Contraindications: GI obstruction, prolonged ileus, diarrhea/vomiting

parenteral +indications +complications

administer nutrients directly into bloodstream, when GI can not be used

indications: chronic severe diarrhea, complicated surgery, GI obstruction, GI fistulas, anorexia, malabsorption, short bowel syndrome

comps: fluid retention and electrolyte imbalance, hypophosphatemia (hallmark), altered renal, fatty acid deficiency, hyper or hypoglycemia, hyperlipidemia, liver dysfunction, air embolus, sepsis, thrombosis, hemorrhage, occlusion, pneumothroax

BMI levels

under 18.5 kg/m = underweight

normal = 18.5-24.9

overweight= 25-29.9

obese = above 30

calculated by weight kg/height in meters squared

waist measurment recommendations

Hip to waist ratio

men greater than 40 and women above 35 inches are at risk

WHR less than 0.8 for women, 1.0 for men (higher number means higher obesity)

Exercise

Goals is 150 minutes of moderate exercise or 75 minutes a week of vigorous exercise, along with strength training

bariatric surgery requirments

BMI above 40

or above 35 with another comorbidity

dumping syndrome

complication of weight loss surgery, gastric contents empty rapidly into small intestine

causes vomiting, nausea, weakness, sweating, fainting, diarrhea - avoid sugary foods