Transcript Lecture 6b Diabetes Management Chapter 19

Lecture 6b
Diabetes Management
Chapter 19
Diabetes Management
• Type 1 diabetes
– Managed by a coordinated regimen of nutrition therapy and insulin;
• Type 2 diabetes
– Diet and exercise
• Gestational diabetes
– Diet and exercise and perhaps insulin
• Goals and interventions are specified for three 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
Diabetes Management—(cont.)
• 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.
o No one proven strategy that can be uniformly
recommended to promote weight loss in all clients
o Weight loss medications
o Bariatric surgery
Diabetes Management—(cont.)
• Preventing diabetes
– Weight loss through a combination of healthy eating and
exercise is the primary focus of diabetes prevention.
– 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 lowers the risk of diabetes.
Diabetes Management —(cont.)
• Secondary prevention: managing diabetes
– Primary goal of diabetes management is to keep blood
glucose levels as near normal as possible.
– Secondary goals
o Attain and maintain control of blood lipid levels and blood
pressure.
o Prevent or delay the development of complications.
o Meet the individual’s cultural and personal needs.
o Maintain the pleasure of eating by not limiting any foods unless
indicated by scientific evidence.
Diabetes Management—(cont.)
• Secondary prevention: managing diabetes—(cont.)
– Nutrition therapy is an essential component of diabetes
management.
– Coronary heart disease (CHD) is the leading cause of death
among people with diabetes.
Diabetes Management—(cont.)
Diabetes Management—(cont.)
Diabetes Management—(cont.)
• Secondary prevention: managing diabetes—
(cont.)
– Total carbohydrates—(cont.)
o Glycemic control depends on matching carbohydrate
intake with the action of insulin or other medication.
o A low glycemic index diet may provide a modest benefit in
controlling postprandial hyperglycemia.
Diabetes Management —(cont.)
• Secondary prevention: managing diabetes—(cont.)
– Sweeteners—
o 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
Diabetes Management—(cont.)
• Secondary prevention: managing diabetes—(cont.)
– Sugar alcohols
o Provide fewer calories and cause a smaller increase in
glucose
o Do not contribute to dental cavities
o Nonnutritive sweeteners
 Saccharin, aspartame, acesulfame, sucralose, and
neotame
 May safely be used by people with diabetes
Diabetes Management—(cont.)
• Secondary prevention: managing diabetes—(cont.)
– Fiber
o Recommendations for fiber are the same as for the
general population.
o Foods rich in fiber provide other benefits such as
increasing satiety; providing vitamins, minerals, and
phytochemicals; and lowering serum cholesterol
levels.
Diabetes Management—(cont.)
• Secondary prevention: managing diabetes—(cont.)
– Fat
o People with diabetes 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.
Diabetes Management—(cont.)
• Secondary prevention: managing diabetes—(cont.)
– Alcohol
o Moderate use of alcohol (1 drink/day or less in women and
2 drinks/day or less in men) by people who have wellcontrolled diabetes minimally affects blood glucose and
insulin levels.
Diabetes Management—(cont.)
• Secondary prevention: managing diabetes—(cont.)
– Vitamins and minerals
o Vitamin and mineral requirements of people with diabetes are
not different from those of the general population.
o Uncontrolled diabetes is often associated with micronutrient
deficiencies.
 Treatment is a balanced diet that supplies natural sources of
nutrients.
o Chromium
Diabetes Management—(cont.)
• 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.
Diabetes Management—(cont.)
• Meal planning approaches—(cont.)
– Exchange lists for meal planning
o Choose Your Foods: Exchange Lists for Meal Planning is a
framework for choosing a healthy diet.
o Group foods into lists that, per serving size given, are
similar in carbohydrate, protein, fat, and calories, based
on rounded averages
o Three major categories are carbohydrates, meat and
meat substitutes, and fats
Diabetes Management—(cont.)
• Meal planning approaches—(cont.)
– Exchange lists for meal planning—(cont.)
o Sample meal pattern is designed for clients based on
their usual pattern of eating.
o Clients are encouraged to eat a variety of foods within
each list and to make healthy choices.
o Food should be weighed or measured until portion sizes
can be accurately estimated.
o Eliminates the need for daily calculations
Diabetes Management—(cont.)
• Meal planning approaches—(cont.)
– Exchange lists for meal planning—(cont.)
o Some items on some lists are counted as more than just
one choice or one exchange.
o Some items appear on more than one list and in different
amounts.
o Best suited to people who want or need structured mealplanning guidance and are able to understand complex
details
Diabetes Management—(cont.)
• 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.
Diabetes Management —(cont.)
• Carbohydrate counting—(cont.)
– 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
Diabetes Management—(cont.)
• Changing behaviors
– Diagnosis of diabetes often triggers anxiety and uncertainty.
– Before recommending dietary changes, it may be useful to
ask the client:
o What are your goals for nutrition counselling?
o What behaviors do you want to change?
o What changes can you make in your present lifestyle?
Diabetes Management—(cont.)
• Changing behaviors—(cont.)
– Before recommending dietary changes, it may be useful to
ask the client:—(cont.)
o What obstacles may prevent you from making
changes?
o What changes are you willing to make right now?
o What changes would be difficult for you to make?
Diabetes Management—(cont.)
• Changing behaviors—(cont.)
– Ideally, positive changes occur progressively.
– Patient actively involved in goal setting, selfmonitoring, and record keeping.
– Periodic and ongoing follow-up improves compliance.
Pharmacologic Management of
Diabetes
• People with type 1 diabetes rely on exogenous insulin for
survival.
• Due to the progressive nature of the disease, most people
with type 2 diabetes eventually require oral agents,
insulin, or a combination of both to manage blood
glucose levels.
Pharmacologic Management of
Diabetes—(cont.)
• Insulin therapy for people with type 1 diabetes
– Insulin preparations vary in how quickly they act,
when their peak action occurs, and how long their effects
last.
– Intermediate- or long-acting insulin is used to meet basal
needs.
– Rapid- or short-acting insulin is used before each meal.
– Closely resembles how insulin is normally secreted
– Nighttime hypoglycemia can be a problem with NPH
peaking during the night.
Pharmacologic Management of
Diabetes—(cont.)
• Intensive insulin therapy for people with type 1
diabetes
– Popular and dynamic insulin regimen for type 1 diabetes
– Algorithm gives formulas for clients to calculate the
carbohydrate-to-insulin ratio for the anticipated
carbohydrate content of a meal/snack.
– Requires more calculations at each meal but allows
greater flexibility in when meals are eaten and how much
carbohydrate is consumed
Pharmacologic Management of
Diabetes—(cont.)
• Insulin therapy for people with type 2 diabetes
– Approximately 30% of people with type 2 diabetes
eventually require insulin.
– Often begins with a single injection of intermediate- or
long-acting insulin at bedtime
– Another regimen uses a morning injection of rapid and
intermediate-acting insulin with an intermediate- or
long-acting insulin at dinner or before bedtime.
– Self-monitoring of blood glucose levels
Pharmacologic Management of
Diabetes—(cont.)
• Glucose-lowering medications
– Oral glucose-lowering medications vary in their
mechanism of action and food concerns.
– Considered adjunct to nutrition therapy and exercise,
not a sole mode of therapy
Exercise—(cont.)
• Exercise in insulin users
– Has not been shown to improve glycemic control in
type 1 diabetics
– May worsen hyperglycemia
– Should occur within 2 hours of eating
– If exercise is unplanned, an additional 10 to 15 g of
carbohydrate per hour of moderate activity is
recommended.
Exercise—(cont.)
• Exercise in type 2 diabetes
– Offers substantial benefits
– Helps to maintain long-term weight reduction
– Monitor blood glucose levels
– Should occur within 2 hours after eating
– Stop activity if signs and symptoms of hypoglycemia
develop
Sick-Day Management
• Acute illnesses can significantly raise blood glucose levels.
• Maintain normal medication schedule, monitor blood
glucose levels every 2 to 4 hours, and maintain an
adequate fluid intake
• A daily intake of 150 to 200 g of carbohydrates,
approximately 45 to 50 g every 3 to 4 hours, is
recommended.
Life Cycle Considerations
• Children and adolescents
– Children with diabetes appear to have the same nutrient
needs as their age-matched peers
– Managing diabetes in children and adolescents is complicated
by the impact of growth on nutrient needs, irregular eating
patterns, and erratic activity levels.
– Failure to provide adequate calories and nutrients results in
poor growth, as does poor glycemic control and inadequate
insulin administration.
Life Cycle Considerations—(cont.)
• Children and adolescents—(cont.)
– Individualized meal plans and intensive insulin
regimens can provide flexibility for erratic eating,
activity, and growth.
– Weight control is key to preventing type 2 diabetes in
children.
Life Cycle Considerations—(cont.)
• Diabetes in later life
– Unique considerations related to aging that affect
glycemic control
– Blood glucose levels rise with age for reasons that are
unclear.
– Cognitive impairments may preclude self-management.
– Older adults may be at greater nutritional risk for a
variety of reasons.
– A fasting target level of 6.7 to 8.3 mmol/L may be
considered appropriate.
Diabetic Diets in the Hospital
• A consistent carbohydrate diet
• Appropriate modifications in fat intake are made.
• Consistent timing of meals and snacks is stressed.
• No one way to provide adequate nutrition for diabetics in
the hospital
Functional foods
Health Canada definition
A functional food is similar in appearance to, or may be, a
conventional food that is consumed as part of a usual
diet, and is demonstrated to have physiological benefits
and/or reduce the risk of chronic disease beyond basic
nutritional functions, i.e. they contain bioactive
compound.
Functional foods
Flaxseed- ground flaxseed may help with
glycaemic control
Nutraceuticals
Health Canada definition
A nutraceutical is a product isolated or purified
from foods that is generally sold in medicinal
forms not usually associated with foods. A
nutraceutical is demonstrated to have a
physiological benefit or provide protection
against chronic disease.
Nutraceuticals
Two examples
Flaxseed oil-high doses may worsen glycaemic
control
Flaxseed lignan complex- 600 mg/day of
secoisolariciresinol diglucoside lowered plasma
glucose in older type 2 diabetes patients