Transcript Diabetes Mellitus

Diabetes Mellitus
Williams’ Basic Nutrition and Diet
Therapy
Chapter 20
Diabetes Mellitus
• Definition:
– Diabetes mellitus refers to a group of
metabolic diseases that are
characterized by an excessively high
(hyperglycemia) blood glucose level
• Disruption of metabolism of
carbohydrates, proteins, and fats
Diabetes Mellitus Incidence
• 246 million people worldwide have diabetes
• 20.8 million Americans have diabetes (7% of
population)
• Estimated total cost of diabetes in US was
$174 billion in 2007 (32% increase since
2002)
• Seventh most common cause of death in US
(mainly due to CV disease)
Diabetes Mellitus Incidence
• African American, Native American,
Latin American, and Asian Americans
have a 3 times higher incidence than
Northern European Americans
• Increased incidence with aging:
> 33% over age of 60
• Males/females equally affected
History of Diabetes
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Symptoms date back to about 1500 BC
Diabetes is Greek meaning siphon
Mellitus is Latin for honey
Insulin comes from the Latin word insula
meaning island
• Paul Langerhans found special clusters of
cells called islets of Langerhans in the
pancreas
Islets of Langerhans Cells
• Special groups of cells
in the pancreas called
alpha, beta, and delta
cells
• Make and secrete the
following hormones
that work together to
regulate blood glucose
levels:
– Insulin, Glucagon,
and Somatostatin
Insulin
• A peptide (chain of amino acids) hormone
produced in the beta cells of the islets of
Langerhans in the pancreas
• Transports glucose into cells for energy
and storage as glycogen in liver and
muscles
• Stimulates free fatty acid storage in fat
deposits
• Stimulates protein synthesis (anabolic
hormone)
Glucagon
• A peptide hormone produced in the alpha
cells of the islets of Langerhans in the
pancreas
• The effect of glucagon is reciprocal to
that of insulin - it raises blood glucose
levels by causing the breakdown of
glycogen in the liver.
• It protects the brain and other tissues
during sleep and fasting.
Somatostatin
• A peptide hormone produced in the
delta cells of the islets of Langerhans
in the pancreas
• It tells the body when to make insulin
and glucagon
Types of Diabetes Mellitus
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Prediabetes
Type 1 Diabetes
Type 2 Diabetes
Gestational Diabetes
Diabetes due to other causes
Prediabetes
• Characterized by blood glucose levels higher than
normal yet not high enough to be diagnosed
• Before contracting diabetes mellitus people
usually have prediabetes:
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Family history of diabetes mellitus
Hypertension
History of gestational diabetes
Low HDL and high LDL levels
Overweight/obesity
Types of Diabetes Mellitus
• Type 1 Diabetes Mellitus
- Formerly known as juvenile onset diabetes
or insulin-dependent diabetes mellitus
• Type 2 Diabetes Mellitus
- Formerly known as adult onset or non
insulin-dependent diabetes mellitus
Type 1 Diabetes Mellitus
• Autoimmune disease (an attack initiated
by the body's immune system against its
own tissues) that effects the beta cells of
the pancreas
• Beta cells do not produce insulin or they
produce it in small amounts that the body
cannot use glucose (blood sugar) for
energy
Type 1 Diabetes Mellitus
• Genetic predisposition to this disease
or a virus may have affected the
pancreas
• Typically occurs in people age 30
years of age and younger
• In most cases, 10-12 in girls and 1214 in boys
Type 1 Diabetes Mellitus
• Insulin injections required
• Different forms of insulin:
– Short, medium, and long acting
• Insulin pumps worn on hip like a
beeper and attach to a long catheter
that can release insulin directly
into the body through a small
needle that is left in the skin
• Insulin pump is more convenient
than injections
• Some success has occurred with
stem cell transplants
Type 1 Diabetes Dietary Strategy
• Individuals need to consume meals and snacks at
regular intervals each day
• A person should consume a simple carbohydrate
if blood glucose level is less than 100 mg per dl
• The simple sugar will be quickly absorbed into
the bloodstream
• People with diabetes should carry high-carb foods
with them all of the time-while exercising, in the
car, at work…
Type 1 Diabetes Overview
Type:
Age of Onset:
Body Weight:
Treatment:
Dietary Strategy:
Insulin Dependent
Usually <30 Years old
Usually Low
Insulin Injections
Increase Calories, Meal
Frequency with
Proper Nutritional
Balance
Type 2 Diabetes Mellitus
• The pancreas does produce insulin, but the
number of insulin receptors may be down
regulated (a decrease in the number of
receptors on the surface of target cells, making
the cells less sensitive to a hormone) ,
resulting in decreased tissue sensitivity to
insulin
• Typically a comorbidity (concurrent health
conditions) of overweight and obesity
Type 2 Diabetes Mellitus
• Usually occurs after the age of 40, but
increased rate of obesity in all ages
• People can usually manage the disease
by losing weight
• Many people take oral hypoglycemic
agents:
– For example: Metformin or glucophage
• Some may require insulin
Type 2 Diabetes Dietary Strategy
• If weight loss recommended, decrease total
daily caloric intake
• Decrease portion size
• Increase meal frequency
• Minimize high starchy foods
• Increase fiber intake
• Limit sweets, sugars and sugar substitutes
• Limit or eliminate alcohol consumption
Type 2 Diabetes Challenge
Try this next time you dine out!
• Ask the waitperson the carbohydrate content of each
item you order
• Try to avoid starchy foods like bread, potatoes & rice
• Be cautious with or avoid any rich sauces or gravies
• Choose fiber- rich vegetables (watch the butter!)
• Eat half your portion (box the rest!)
• Limit yourself to one alcoholic beverage
• No dessert!!!
Type 2 Diabetes Overview
Type:
Age of Onset:
Body Weight:
Treatment:
Dietary Strategy:
Insulin Resistant
Usually >40 Years old
Usually Overweight
Weight Loss, Exercise,
Oral Hypoglycemic
agents
Decrease Calories with
Proper Nutritional
Balance
Gestational Diabetes
• Characterized by high blood glucose
levels during pregnancy
• All diabetic symptoms usually disappear
following delivery
• Treatment for gestational diabetes
includes special diet, exercise, and insulin
injections
Diabetes Due to Other Causes
• Metabolic Syndrome- Following conditions
must be present:
– Obesity: abdominal obesity greater than 40
inches in males and 35 inches in females
– Blood Pressure greater than 130/85mmHg
– Fasting blood glucose levels >110 mg per dl
– HDL cholesterol levels: <40 mg per dl in
men and <50 mg per dl in females
– Triglyceride levels: >150 mg per dl
Diabetes Due to Other Causes
• Genetic defects
• Pancreatic Conditions or Disease
• Endocrinopathies (Hormone Dysfunction)
-Cushing’s Syndrome
-Pheochromocytoma
-Aldosteronoma
• Drug or Chemical Induced Diabetes
Medical Diagnosis of Diabetes
Mellitus
• Primary tests used:
– Fasting plasma (blood) glucose test (FPG)
– Oral glucose tolerance test (OGTT)
• FPG is assessment of blood glucose levels when a
person has fasted
• The OGTT is measured both at fasting and then 1
and 2 hours after consumption of a glucose
beverage (50 g)
Medical Diagnosis of Diabetes Mellitus
• Fasting plasma glucose > 126 mg/dl after no caloric
input for at least 8 hr.
or
• Classic symptoms of diabetes + glucose level > 200
mg/dl
or
• 2-hour postload glucose > 200 mg/dl during an oral
glucose tolerance test
Medical Diagnosis of Diabetes Mellitus
FPG
OGTT
Signs and Symptoms of Diabetes Mellitus
• Polyuria:
– increased frequency of urination
• Polydipsia:
– increased thirst
• Polyphagia:
– increased appetite
• Lethargy:
– general weakness
Signs and Symptoms of Diabetes Mellitus
• Repeated infections or sores that heal slowly or not
at all
• Blurred vision
• Tingling or numbness in hands or feet
• Ketoacidosis
Ketoacidosis
• The body cannot use glucose for energy
because little or no insulin is present to deposit
glucose into cells
• Body starts to break down its fat stores for
energy
• Although fat has more energy than
carbohydrates excessive breakdown of fat
leads to a buildup of ketone bodies
Ketoacidosis
• The CNS can use ketone bodies for a short time
(prefer glucose) but the build up of ketone bodies
makes the blood more acidic and results in
ketoacidosis:
– A life-threatening condition in which ketones (result
from the breakdown of fat for energy) accumulate in
the bloodstream and the pH of the blood decreases
– May lead to a coma and possibly death
• Moderate or large ketones are present in the urine
as well as in the body
Measuring for Ketones
• A blood test is the most accurate method of
measuring ketones
• A urine test is the most commonly used
method of measuring ketones
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Low Carbohydrate Diets
• The goal of high protein low carbohydrate diets is
to increase ketone production in the body
• The negative effect of high ketone bodies is that
they will not sustain the energy needed for the
brain and spinal cord which prefers glucose
• Ketoacidosis may occur, which may lead to a
coma
Low Carbohydrate Diets
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Q: Does ketosis help lose weight?
A: Yes.
Q: Is it safe?
A: I wouldn't recommend it. I think it
is a dangerous way to lose weight.
Long Term Complications of Uncontrolled
Diabetes Mellitus
• Retinopathy:
– Disease of the eyes that can lead to blindness
– Diabetes mellitus is the leading cause of
blindness in people 20 to 74 years of age
• Nephropathy:
– Disease of the kidneys that can lead to kidney
failure
• Heart Disease (HTN/Dyslipidemia/CAD)
Long Term Complications of Uncontrolled Diabetes
Mellitus
•Neuropathy:
•Disease of the
peripheral nervous
system that can cause
loss of sense of feeling,
which often leads to
wounds that never heal
because the person does
not feel them.
•Amputations may result
if these infections result
in gangrene
Exercise Clearance
• Before beginning an exercise program, clients with
diabetes mellitus should have medical clearance from
their physician
• Exercise enhances the absorption of insulin, increases
the muscle uptake of glucose, and impairs the
mobilization of glucose in blood
Glycemic Control and Exercise
• Moderate to intense activity may cause blood
glucose levels to decrease after 24 hours
• If blood glucose levels are less than 100 mg
per dl immediately after exercise the
individual should do the following:
– Increase carbohydrate intake before exercise
– Decrease insulin dosage following exercise
– Consume a carbohydrate and protein snack
Hypoglycemia
• The major goal is to prevent hypoglycemia (blood glucose
level of 65 mg per dl or lower) as a result of exercise
• Recommendations:
– Measure blood glucose before, during, and after exercise
– During exercise, easily absorbable carbohydrate may have to be
consumed
– After exercise, an extra carbohydrate-rich snack may be necessary
– Consume 15g of carbohydrate if not planning to eat 30-60 minutes
before exercise
– Take in 15 grams of carbohydrate and 7 grams of protein if not
planning to eat for more than 60 minutes before exercise
Hypoglycemia During Exercise
• May be caused by:
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Increased exercise intensity
Longer exercise duration
Inadequate caloric intake prior to exercise
Not eating on time
Missing meals
Taking too much insulin
Insulin injection into exercising muscle
Colder environmental temperatures
Hypoglycemia
• Emergency situation (consider calling 911)
• If blood glucose levels drop the individual may
become confused, disoriented, or lose
consciousness
• Greater concern for clients with type 1 diabetes
mellitus
Signs and Symptoms of Hypoglycemia
• Cold clammy or sweaty
skin
• A staggering gait
• Abdominal pain or
nausea
• Excessive hunger
• Headache
• Shaking or shivering
• Irritability, hostility
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Blurry vision
Tachycardia
Dizziness
Confusion
Convulsion
Syncope (fainting)
Unconsciousness
Coma
Sweating
Responding to a Client Who Has Hypoglycemia
• Clients with diabetes should always wear a
medical alert bracelet in case of a
hypoglycemic reaction
• Do not leave client alone
• Measure blood glucose level with a glucose
monitor device if available
• Give sugar immediately!
Responding to a Client Who Has Hypoglycemia
• If blood glucose level is below 70 mg per dl, provide 15 g
of carbohydrate, which is equivalent to:
– About 3-4 glucose tablets
– 3 packets of table sugar dissolved in water
– ½ cup of fruit juice or soft drink
– 6 life savers
– 1 tablespoon of honey
– 6 saltine crackers
• Wait 10-15 minutes, treat again and remeasure glucose
level until blood glucose level rises above 70 mg per dl.
Hyperglycemia
• High blood glucose levels due to too
much food, not enough insulin, illness, or
stress
• Do not give sugar if individual is
unconscious, having a seizure, or unable
to swallow
• Call 911!
Signs and Symptoms of Hyperglycemia
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Nausea
Drowsiness
Blurry vision
Vomiting
Extreme thirst
Frequent urination
Contraindications to Exercise
• Blood glucose levels greater than 240 mg per dl and ketones
in urine for type 1 diabetes
• Blood glucose greater than 300 mg per dl without ketones
• Clients with retinopathy should avoid strenuous high
intensity activity
• Severe kidney disease
• Clients with a loss of protective sensation in the feet should
avoid outdoor walking and jogging. Swimming and biking
is recommended.
• Acute illness, infection, or fever
• Evidence of underlying cardiovascular disease that has not
been medically evaluated
Guidelines For Safe Exercise
• Do not exercise when insulin is working at peak
action
• Don’t inject insulin into a part of the body you will
be exercising. It will be absorbed faster there.
• Eat a small snack or drink fruit juice 15-20 minutes
before exercising if blood sugar levels are below
100mg/dL
• The personal trainer should not give advice to the
client about the use of insulin or timing of meals
Benefits of Exercise
• Improved insulin sensitivity
• Improved blood lipids and lipoproteins
• Increased caloric expenditure resulting in reduction or
maintenance of body weight, reduction in body fat, and
preservation of lean body mass
• Improved physical fitness
• Improved flexibility and strength
• Decreased BP in those with hypertension
• Decreased risk of cardiovascular disease
• Improved psychological well-being, including enhanced
quality of life, improved self esteem
Aerobic Conditioning Guidelines for
People with Diabetes Mellitus
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Frequency: 4-6 days or daily
Duration: 20-60 minutes
40-70% VO2
Monitor exercise intensity via RPE
A snack may be needed before exercise
Monitor blood glucose before and after
exercise
• Include a 5-10 minute warm-up and cool-down
period
• Large muscle activities
Resistance Training for People with
Diabetes Mellitus
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Frequency: 2-3 nonconsecutive days/week
Muscular Endurance: 1-3 sets/10-15 reps
Up to 8-10 exercises
Can begin with body weight exercises and
progress to free weights and machines
• Clients with well controlled diabetes can
progress to strength training
Flexibility Training for People with
Diabetes Mellitus
• Minimum of 2-3 sessions per week
• Hold static stretches for 10-30 seconds
• Yoga is a good example for flexibility
training
Basic Elements of Diabetes
Management
1. Healthy diet for good glucose management
2. Physical exercise provides an important
balance to maintain good glucose control
3. Medications ensure adequate insulin activity
4. Introduce stress coping skills to reduce
hormonal imbalance (yoga, meditation)