Nutrition - Diabetes Mellitus

Diabetes

a group of metabolic diseases characterized by hyperglycemia

Causes of Hyperglycemia

from defects in insulin secretion, insulin action, or both

Chronic hyperglycemia

Long-term damage, dysfunction, and failure of various body organs

diabetes ranks what among leading cases of death in the US

seventh

diabetes contributes to

heart and kidney failure

Diagnosis of Dm

- A1C >6.5%

- Fasting BG >126mg/dL

- 2 hour BG >200 after oral glucose tolerance tests

- random plasma glucose >200mg/dL

- national glycohemoglobin standardization program

Type I

5-10%

autoimmune disease that leads to destruction of beta cells

Type II

90-95%

progressive insulin secretor defect, insulin resistance

Gestational Diabetes

2-10% of pregnancies

diabetes identified during pregnancy, insulin resistance brought on by pregnancy hormones

Age of onset for type I

usually before 30

Age of onset for type II

usually after 30

causes for type I

genetic predisposition; autoimmune reaction; environmental exposure

causes for type II

strong genetic disposition; insulin resistance due to cell receptor defect; decreased insulin secretion; excess production of glucose from the liver

major defect for type I

destruction of pancreatic beta cells; insulin deficiency

major defect for type II

insulin resistance; insulin deficiency

characteristic for type I

abrupt onset of S/S of hyperglycemia; ketosis prone

characteristics for type II

Frequently obese; not prone to ketoacidosis until late in course or with prolonged hyperglycemia; may or may not have symptoms of hyperglycemia

treatment for type I

Insulin; MNT; physical activity; DSME; self-monitoring of blood glu and ketones.

treatment for type II

Diet/weight management; physical activity; oral meds and/or insulin; self monitoring of blood glucose; treatment of comorbid conditions

Insulin

anabolic hormone that helps store glucose as glycogen in muscle and liver

Amylin

causes satiety, lowers post-prandial glucagon response, slows gastric emptying

Glucagon

stimulates the liver to convert glycogen to glucose

Glucagon affect on glucose

increase

epinephrine affect on glucose

increase

Insulin affect on glucose

decrease

Amylin affect on glucose

decrease

S/S of type I

polydipsia, polyphagia, polyuria, weight loss, KDA

weight loss related to type I

insulin deficiency leads to an increase in protein breakdown, leading to muscle wasting and growth retardation

DKA

insulin insufficiency leads to a increase in triglyceride breakdown in adipose tissue, increasing blood fatty acids that become oxidized in the liver and lead to an increase in ketone body production

Treatment for type I

Insulin therapy, blood glucose monitoring, medical nutrition therapy, physical activity

who is at risk for Type II

- first degree relative with DM

- high risk ethnic group

- overweight/obesity

- physical inactivity

- Hx GDM

- Baby with birth weight above 9 LBS or low birth weight

- METABOLIC SYNDROME

Metabolic syndrome

hyperglycemia, abdominal obesity, hypertension, reduced HDL, elevated triglycerides

reduced HDL

Elevated triglycerids

>150 or adults undergoing treatment for elevated trigs

7 Self-Care behaviors for type 2 DM treatment

1) healthy coping

2) healthy eating

3) being active

4) taking medication

5) monitoring

6) reducing risks

7) problem solving

Pathophysiology of DKA

TYPE 1 DM

lack of insulin stimulates fat and muscle breakdown --> increased supply of fatty acids and amino acids arrive in the liver --> fuels production of ketone bodies and glucose

DKA S/S

nausea, vomiting, abdominal pain, dehydration

Treatment of DKA

Hydration (hydration with insulin drop followed by giving long-acting insulin dose), insulin, monitoring

HHS Classification

primarily classified by profound dehydration (high osmolality)

HHS Pathophysiology

TYPE 2 DM

insulin levels are insufficient to allow appropriate glucose utilization --> insulin levels are adequate to lipolysis --> which could lead to ketogenesis

HHS S/S

Evolves slowly. Prolonged hyperglycemia >600 mg/dL; may rise to above 2000 mg/dL. Severe dehydration. Confusion (often mimics stroke). Usually no nausea, vomiting, or abdominal pain. Sometimes first sign of type 2 diabetes in elderly. Mortality rate around 15%.

Treatment for HHS

Hydration, find underlying cause and treat, insulin drip, electrolytes (potassium replacement)

Diagnostic criteria for DKA and HHS: Plasma Glucose

Severe DKA: > 250

HHS: >600

Diagnostic criteria for DKA and HHS: Arterial pH

Severe DKA: < 7.00

HHS: > 7.30

Diagnostic criteria for DKA and HHS: Sodium Bicarbonate

Severe DKA: < 10

HHS: > 15

Diagnostic criteria for DKA and HHS: Urine Ketones

Severe DKA: Positive

HHS: Small

Diagnostic criteria for DKA and HHS: Serum Ketones

Severe DKA: Positive

HHS: Small

Acanthosis Nigricans

velvety brown markings, usually on the neck, under the arms, or groin

Acanthosis Nigricans cause

Insulin "spills over" into skin, activating insulin receptors in skin & causes abnormal growth

Acanthosis Nigricans treatement

Reduction of circulating insulin by healthy diet and exercise

When to test for gestational diabetes

between 24 and 28 weeks

GDM affects on baby

- baby overproduces insulin which then acts as a growth hormone

- respiratory distress and metabolic problems

- Macrosomia

- Shoulder dystocia

- higher risk for obesity and type 2 DM as children

Causes of hypoglycemia

- Medication: frequent adjustment, irregular timing, too much

- Food: not enough, poor nutrition, alcohol

- physical activity: not enough food, excessive or unplanned

Hypoglycemic symptoms

Autonomic, neuroglycopenic, unknown etiology

Autonomic symptoms

trembling, shaking, sweating, pounding heart, fast pulse, tingling in extremities

Neuroglycopenic Symptoms

slow thinking, blurred vision, slurred speech, poor coordination, numbness, trouble concentrating, dizzy, fatigue

Unknown Etiology Symptoms

Hunger, nausea, weakness, headache, general feeling of something not right

Treatment for mild to moderate hypoglycemia

15/15 Rule

15/15 Rule

- If BG < 70, take 15 gram of a quick acting carb ( should raise BG 30-45 mg/dL_

- wait 15 mins

- recheck BG

- if BG is still < 70, give another 15 gram snack

- one BG is above 70, eat a meal of snack

- IF BG IS < 50, treat by eating or drinking 30 grams of carbohydrate

15 gram carbohydrate examples

- 1/2 cup fruit juice (not light or sugar free)

- 6 ounces regular soda

- 1 cup fat-free milk

- 4 glucose tablets

- 6 lifesavers

- 3 pieces of hard candy

- 2 tablespoons of raisins

Self treatment guidelines for hypoglycemia

Do, Avoid, Carry, Wear, Determine

Do

Don't over treat: stop eating after initial treatment, even if symptoms have not stopped

Avoid

Avoid using high fat foods

Carry

Always carry quick acting carbs

Wear

Wear ID

Determine

determine cause and problem solve

Severe hypoglycemia if able to swallow without risk of aspiration

try glucose gel or honey inside cheek

Severe hypoglycemia if unable to swallow without risk of aspiration

- requires IV push of D50 or gucagon injection

- Home: Gvoke HypoPen

Severe hypoglycemia hospital protocol

IV administration of dextrose

Hyperglycemia S/S

increased thirst and urination, ketones in urine, weakness, stomach pain, general aches, Kussmaul respirations, loss of appetite, nausea, vomiting, fatigue

ADA

Goals for caring for DM

Glycemic Control: fasting and before meals

ADA: 80 - 13- mg/dL

AACE: < 110 mg/dL

Gestational:

Glycemic Control: after meals

ADA:

How often should you measure A1C

every 3 to 6 hours

Blood Pressure Guidelines

Normal:

Total Cholesterol

Triglycerides

LDL Cholesterol

HDL

Female: >50 mg/dL

Male: >40 mg/dL

(60 mg/dL favorable for both)

Lispro (Humalog)

onset: 5-15 min

peak: 0.5-1.5 hour

Aspart (novolog)

Onset: 5-10 min

Peak: 1-3 hr

Glulisine (Apidra)

Onset: 5-15 mins

Peak: 1 - 1.5 hrs

Regular Insulin

Onset: 30-60 mins

Peak: 2-3 hrs

Type 1 DM Dosing

up to 1 unit/kg/day

Type 2 DM Dosing

varies (may start with 4-6 units before meals of 0.1 units/kg/meal)

Insulin-to-Carb Ratio

Adult (normal weight) - 1:10 to 1:15

Adult (overweight) - 1:7 - 1:10

Adult (obese) - 1:5

500 rule for ICR

500/TDD

Which nutrients affect blood glucose the most

carbs, then proteins, then fats

carbohydrate foods

starch, fruit, milk, desserts

how many grams is a carb serving

15

Carb Counting - starch

each food has 80 calories and 15 grams of carbs

- 1/2 cup cooked beans

- 1 small ear of corn of 1/2 cup of corn

- 1/3 cup cooked pasta

- 3/4 cup dry cereal

- 1/33 cup cooked rice

- 1 slice of bread

- 1 small potato or sweet potato

- 1 small tortilla

- 5-6 small crackers

- 1/2 English muffin

Carb Counting - Fruit

Each food has 60 calories and 15 grams of carbs:

- 1 small fresh fruit

- 1/2 cup canned fruit packed in juice

- 1/2 banana

- 1/2 cup unsweeted apple sauce

- 17 small grapes

- 1.25 cup melon

- 1/4 cup dried fruit

- 2 tbs raisings

- 1 cup berries

Carb Counting - Milk

Each food has 90-150 calories and 12-15 grams of carbs:

- 1 packed non-added-sugar hot cocao

- 8 oz buttermilk

- 6 oz plain yogurt

- 6 oz light fruit yogurt

- 8 oz vanilla soy milk

- 8 oz milk

Carb Counting - Sweets

Each food has 15 grams of carbs, calories varie:

- 2 inch square cake of brownie

- 1/2 cup no-sugar added pudding

- 1/2 cup regular jello

- 2 tbsp light syrup

- 1 tbsp syrup, jam, jelly, sugar, honey

- 1/4 cup sorbet/sherbert

- 1/2 cup ice cream or frozen yogurt

- 2 small cookies

foods that don't raise blood sugar

non-starchy vegetables, meat, fat, "free" foods

non-starchy veggies contain

FIBER, aim for 25-35 grams of fiber/day

Free foods

less than 5 grams of carbs of less than 20 calories per serving

free foods examples

-Broth

-Coffee, tea, diet soda

-Diet gelatin

-Light cool whip

-Dill pickles

-Herbs, spices and seasonings

-Some condiments (ketchup, mustard, salsa)

- salad greens

Handy Meal Plan

- Carbohydrate: each finger = 15 grams. may have 2-4 servings per meal

- protein: palm of hand = 3 oz

= Fat: thumb tip = 1 tsp

Weight management goals

- 5-10 % weight loss over 3-6 months