Nutrition for Patients with Diabetes Mellitus Chapter 19

1. Nutrition for Patients with Diabetes MellitusChapter 19

2. Nutrition for Patients With Diabetes Mellitus • Glucose circulating in the blood is a source of ready fuel for body cells • The amount of carbohydrate consumed and the type of carbohydrate eaten are the primary determinants of how quickly and how high blood glucose levels rise after eating • A rise in postprandial blood glucose levels stimulates the pancreas to secrete insulin • Fasting blood glucose levels over 126 mg/dL indicate diabetes

3. Diabetes • Diabetes is one of the most costly and burdensome chronic diseases of our time • Increasing in epidemic proportions • The estimated direct and indirect cost associated with diabetes in 2007 was $174 billion • The CDC estimates that one in three children born in the U.S. in 2000 will have diabetes in his or her lifetime; for Hispanics, the estimate is one out of two

4. Diabetes (cont’d) • Type 1 diabetes • Formerly known as insulin-dependent diabetes mellitus • Characterized by the absence of insulin • Risk factors for type 1 diabetes may be: • Autoimmune • Genetic • Environmental

5. Diabetes (cont’d) • Type 1 diabetes (cont’d) • No known way to prevent type 1 diabetes • All people with type 1 diabetes require exogenous insulin to control blood glucose levels • Most often detected in children, adolescents, and young adults • Classic symptoms of polyuria, polydipsia, and polyphagia

6. Diabetes (cont’d) • Type 2 diabetes • Occurs most often after the age of 45 • Accounts for 90% to 95% of diagnosed cases of diabetes • A slowly progressive disease that usually begins as a problem of insulin resistance • Type 2 diabetes is often asymptomatic

7. Diabetes (cont’d) • Type 2 diabetes (cont’d) • Insulin resistance is strongly linked to obesity • Risk factors for type 2 diabetes • Age 45 years or older • Overweight (BMI ≥25 kg/m2) • First-degree relative with diabetes • Physically inactive or exercises fewer than 3 times/week

8. Diabetes (cont’d) • Risk factors for type 2 diabetes (cont’d) • Member of high-risk ethnic group: African American, Latino, Native American, Asian American, Pacific Islander • Previously identified with prediabetes such as impaired fasting glucose or impaired glucose tolerance • History of gestational diabetes or giving birth to a baby weighing more than 9 pounds • Hypertensive • HDL <35 mg/dL and/or triglyceride level ≥250 mg/dL

9. Diabetes (cont’d) • Many of the risks for type 2 diabetes are characteristics of metabolic syndrome (MetS) • People with MetS are twice as likely to develop heart disease and five times as likely to develop diabetes compared to those without • Estimated that more than two thirds of people with type 2 diabetes have metabolic syndrome • Even modest weight loss can lessen the risks associated with metabolic syndrome

10. Diabetes (cont’d) • Modifiable risk factors for metabolic syndrome include excess body fat, a sedentary lifestyle, and a high–saturated-fat diet

11. Gestational diabetes • Hyperglycemia that develops during pregnancy • Risk factors: • A family history of gestational diabetes • Obesity, being a member of a certain ethnic population (Native Americans, Hispanic Americans, Mexican Americans, African Americans, Asian Americans, and Pacific Islanders) • A history of giving birth to an infant weighing more than 9 pounds

12. Gestational diabetes (cont’d) • All women are routinely screened between 24 and 28 weeks’ gestation • Immediately after pregnancy, 5% to 10% of women with gestational diabetes are diagnosed with diabetes, usually type 2

13. Question • Type 1 diabetes, once referred to as insulin- dependent diabetes, is caused by what? a.Hyperinsulinemia b. Absence of insulin c. Sensitivity to insulin d. Metabolic syndrome

14. Answer b. Absence of insulin Rationale: Type 1 diabetes, formerly known as insulin-dependent diabetes mellitus, is characterized by the absence of insulin.

15. Acute Diabetes Complications • Untreated or poorly controlled diabetes can lead to acute life-threatening complications • Conversely, hypoglycemia caused by overuse of medication, too little food, or too much exercise, can also be life threatening

16. Acute Diabetes Complications (cont’d) • Diabetic ketoacidosis (DKA) • People with type 1 diabetes are susceptible to diabetic ketoacidosis (DKA) • Characterized by hyperglycemia (glucose levels >250 mg/dL) and ketonemia • Caused by a severe deficiency of insulin or from physiologic stress, such as illness or infection

17. Acute Diabetes Complications (cont’d) • Diabetic ketoacidosis (DKA) (cont’d) • Polyuria may lead to dehydration, electrolyte depletion, and hypotension • Hyperventilation occurs in an attempt to correct acidosis by increasing expiration of carbon dioxide • Fatigue, nausea, vomiting, and confusion develop • Diabetic coma and death are possible

18. Acute Diabetes Complications (cont’d) • Diabetic ketoacidosis (DKA) (cont’d) • DKA is sometimes the presenting symptom when type 1 diabetes is diagnosed • DKA rarely develops in people with type 2 diabetes • DKA is treated with electrolytes, fluid, and insulin

19. Acute Diabetes Complications (cont’d) • Hyperosmolar hyperglycemic nonketotic syndrome (HHNS) • Characterized by hyperglycemia (>600 mg/dL) without significant ketonemia • Occurs most commonly in people with type 2 diabetes • Dehydration and heat exposure increase the risk • Illness or infection is usually the precipitating factor

20. Acute Diabetes Complications (cont’d) • Hyperosmolar hyperglycemic nonketotic syndrome (HHNS) (cont’d) • Older people may be particularly vulnerable • Develops relatively slowly • Symptoms • Best protection against HHNS is regular glucose monitoring • Treatment includes insulin and fluid and electrolyte replacement

21. Acute Diabetes Complications (cont’d) • Hypoglycemia • Blood glucose level less than 70 mg/dL • Commonly referred to as “insulin reaction” • Occurs from taking too much insulin, inadequate food intake, delayed or skipped meals, extra physical activity, or consumption of alcohol without food • Symptoms

22. Acute Diabetes Complications (cont’d) • Hypoglycemia (cont’d) • Mild hypoglycemia is treated with 15 to 20 g of glucose • Symptoms normally improve in 10 to 20 minutes • Hypoglycemic unawareness • Consistent monitoring of blood glucose is especially important

23. Question • Is the following statement true or false? Diabetic ketoacidosis is characterized by glucose levels greater than 250 mg/dL.

24. Answer True. Rationale: People with type 1 diabetes are susceptible to diabetic ketoacidosis (DKA), characterized by hyperglycemia (glucose levels >250 mg/dL) and ketonemia.

25. Long-Term Complications (cont’d) • Mild to severe forms of nervous system damage • Impaired wound healing • Periodontal disease • Pregnancy complications • Increased susceptibility to other illnesses

26. Diabetes Management • Type 1 diabetes • Managed by a coordinated regimen of nutrition therapy and insulin • Type 2 diabetes • Diet and exercise

27. Diabetes Management • Goals and interventions are specified for 3 levels of prevention: • Primary prevention of diabetes among people with prediabetes or at high risk of diabetes • Secondary prevention of managing existing diabetes • Tertiary prevention of slowing the rate of diabetes complications

28. Diabetes Management (cont’d) • Calories, overweight, and obesity • Weight loss has traditionally been the focus of nutrition intervention for overweight and obese people with prediabetes or type 2 diabetes • No one proven strategy that can be uniformly recommended to promote weight loss in all clients • Weight loss medications • Bariatric surgery

29. Preventing diabetes • Weight loss through a combination of healthy eating and exercise is the primary focus of diabetes prevention • Diabetes Prevention Program (DPP) • A low–saturated-fat intake may reduce the risk for diabetes by improving insulin resistance and promoting weight loss • Several studies show that an increased intake of whole grains and fiber lower the risk of diabetes

30. Secondary prevention: managing diabetes • Primary goal of diabetes management is to keep blood glucose levels as near normal as possible

31. Secondary prevention: managing diabetes • Secondary goals • Attain and maintain control of blood lipid levels and blood pressure • Prevent/delay complications • Meet the individual’s cultural and personal needs • Maintain the pleasure of eating by not limiting any foods unless indicated by scientific evidence

32. Secondary prevention: managing diabetes (cont’d) • Nutrition therapy is an essential component of diabetes management • Coronary heart disease (CHD) is the leading cause of death among people with diabetes • Total carbohydrates • RDA for carbohydrates is 130 g/day • Acceptable macronutrient distribution range (AMDR) is 45% to 65% of total calories

33. Secondary prevention: managing diabetes (cont’d) • Total carbohydrates (cont’d) • Glycemic control depends on matching carbohydrate intake with the action of insulin or other medication • A low–glycemic-index diet may provide a modest benefit in controlling postprandial hyperglycemia • Sweeteners • Sucrose and sucrose-containing foods are not restricted • Foods high in sugar are usually nutrient poor

34. Diabetes Management (cont’d) • Secondary prevention: managing diabetes (cont’d) • Sweeteners (cont’d) • Use of fructose as an added sweetener is not recommended • May adversely affect serum lipid levels • No reason for people with diabetes to avoid naturally occurring fructose in fruit and vegetables

35. Secondary prevention: managing diabetes (cont’d) • Sugar alcohols • Provide fewer calories and cause a smaller increase in glucose • Do not contribute to dental cavities • Nonnutritive sweeteners • Saccharin, aspartame, acesulfame, sucralose, and neotame • May safely be used by people with diabetes

36. Secondary prevention: managing diabetes (cont’d) • Fiber • Recommendations for fiber are the same as for the general population • Foods rich in fiber provide other benefits such as increasing satiety; providing vitamins, minerals and phytochemicals; and lowering serum cholesterol levels

37. Secondary prevention: managing diabetes (cont’d) • Fat • People with DM appear to have the same CV risk as people with preexisting CV disease • People with DM are advised to limit their intake of saturated fat to less than 7% of total calories, minimize their intake of trans fat, and consume less than 200 mg of cholesterol daily • Little difference from AHA recommendations

38. Secondary prevention: managing diabetes (cont’d) • Protein • In the American diet, protein provides 15% of total calories • Alcohol • Moderate use of alcohol (1 drink/day or less in women and 2 drinks/day or less in men) by people who have well-controlled diabetes minimally affects blood glucose and insulin levels

39. Secondary prevention: managing diabetes (cont’d) • Vitamins and minerals • Vitamin and mineral requirements of people with diabetes are no different from those of the general population • Uncontrolled diabetes is often associated with micronutrient deficiencies • Treatment is a balanced diet that supplies natural sources of nutrients

40. Tertiary prevention: controlling diabetes complications • Progression of microvascular diabetes complications may be modified by improving glycemic control and lowering blood pressure • Meal planning approaches • Monitoring carbohydrate intake is key to controlling blood glucose levels • Meal plan should reflect the individual’s lifestyle, preferences, and willingness/ability to make dietary changes

41. Meal planning approaches (cont’d) • Exchange lists for meal planning • Choose Your Foods: Exchange Lists for Meal Planning is a framework for choosing a healthy diet • Groups foods into lists that, per serving size given, are similar in carbohydrate, protein, fat, and calories, based on rounded averages • Three major categories are Carbohydrates; Meat and Meat Substitutes; and Fats

42. Exchange lists for meal planning (cont’d) • Sample meal pattern is designed for clients based on their usual pattern of eating • Clients are encouraged to eat a variety of foods within each list and to make healthy choices • Food should be weighed or measured until portion sizes can be accurately estimated • Eliminates the need for daily calculations

43. Exchange lists for meal planning (cont’d) • Some items on some lists are counted as more than just one choice or one exchange • Some items appear on more than 1 list and in different amounts • Best suited to people who want or need structured meal-planning guidance and are able to understand complex details

44. Carbohydrate counting • Easier and more flexible alternative to using the exchange system • Clients are given an individualized meal pattern that specifies the number of carbohydrate “choices” for each meal and snack • Carbohydrate choice lists • Protein and fat cannot be disregarded

45. Carbohydrate counting (cont’d) • Appropriate for people who understand the importance of consuming a consistent carbohydrate intake to match insulin or medication peaks • Feel more in control and benefit from improved glucose control • Keeping records of blood glucose tests and food intake helps

46. Changing behaviors • Diagnosis of diabetes often triggers anxiety and uncertainty • Before recommending dietary changes, it may be useful to ask the client: • What are your goals for nutrition counseling? • What behaviors do you want to change? • What changes can you make in your present lifestyle?

47. Changing behaviors (cont’d) • Before recommending dietary changes, it may be useful to ask (cont’d): • What obstacles may prevent you from making changes? • What changes are you willing to make right now? • What changes would be difficult for you to make?

48. Changing behaviors (cont’d) • Ideally, positive changes occur progressively • Patient actively involved in goal setting, self-monitoring, and recordkeeping • Periodic and ongoing follow-up improves compliance

49. Question • Is the following statement true or false? Sugar alcohols do not contribute to dental cavities.

50. Answer True. Rationale: Sugar alcohols do not contribute to dental cavities yet using them is not likely to produce weight loss or improve glycemic control.