diabetes pdf
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CH 20Nutrition and
DiabetesMellitus
What is Diabetes Mellitus?Treatment of Diabetes MellitusDiabetes Management throughout Life
2005 Pamela Eccles All Rights Reserved
What isDiabetes Mellitus ?
A group of metabolic
disorders of glucoseregulation and utilization
Characterized by
Elevated glucose
Altered energymetabolism
Caused by
Defective insulin secretion
Defective insulin action
Or
a combination of
10 million in U.S.diagnosed
+ 5.5 million more notdiagnosed..
Types of Diabetes
Type IType 2
Type 1Characteristics Less common
5-10% of cases Pancreas cannot
make insulin Blood glucose rises Without insulin
Glucose cannot enter cell
like it should Insulin must be injected
Type 2
Characteristics
90-95 % of cases
Most likely undiagnosed
Pancreas does produce insulin
Cells not sensitive to (tolerance)
Pancreas makes more insulin Cells in pancreas which make
insulin exhaust
Insulin production falters
Associated w/ obesity
Abdominal fatespecially
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Symptoms
Type 1
Frequent urination
Unusual thirst
Extreme hunger
Unusual weight loss
Extreme fatigue
Irritability
Type 2Any type 1 symptom(s)
PlusFrequent infectionsBlurred visionCuts/bruises - slow to healTingling/numbness in
hands or feetRecurring gum/skin/
bladder infections
People most likely todevelop Type 2diabetes
Are those who
are obese have immediate family
members w/.
are over age 45 are members of high risk
ethnic groups
African Americans
Asian and PacificIslanders
Hispanic Americans
Native Americans
Also
Women who have givenbirth to babies weighingover 9 lbs. or have beendiagnosed w/ gestationaldiabetes while pregnant
Nursing Diagnosis Altered nutrition: more than
body requirements
and
altered nutrition: risk for morethan body requirements
Diagnosis of Diabetes
Random blood glucosesamples
Exceed 200mg/100ml
Or
Blood glucose of 126mg/100ml w/ 8 hour fast
Blood glucose level>200mg/100ml any timeduring a glucose tolerancetest
These suggestdiabetes.
To confirm positive
Second testing Subsequent day
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Acute Complications
of Diabetes
Hyperglycemia, Dehydration,and Glycosuria
Blood glucose -hyperglycemia
Water drawn from tissues intoblood
Kidneys overwhelmed
Glucose excreted w/ fluids andelectrolytes
Glycosuria
Renal threshold The point at which a
blood constituent that isnormally reabsorbed bythe kidneys reaches alevel so high thekidneys cannotreabsorb it
The Nursing Diagnosis:
Fluid volume deficit or riskfor fluid volume deficit
Hyperglycemia
May develop in response to
Carbohydrate eaten
Type
Amount
Improper use of meds
in counterregulatoryhormones
Dawn phenomenon
Early morning hyperglycemia thatdevelops in response to elevated levelsof counterregulatory hormones that actto raise blood glucose after anovernight fast. Without adequateinsulin, the glucose cannot enter cellsand remains in blood
Strenuous exercise
Can cause a sharp rise in bloodglucose
Use of too much insulin
Rebound hyperglycemia
Hyperglycemia resultingfrom excessive secretions ofcounterregulatory hormonesin response to excessiveinsulin and consequent lowblood glucose levels;Somogyi effect
Illness/infection
Ketosis and Coma
Undiagnosed Type 1 diabetes
Cells deprived of glucose forenergy
Breakdown of protein and fatenergy
Liver makes ketone body from fatfragments
Build up of ketones in urine andblood acidosis
Fruity breathacetone
Diabetic coma may follow
Medical emergency
Treated in hospital
IV fluids
Fluid balance
Electrolytes
Acid imbalance
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Nonketotic Coma
(Hyperosmolar hyperglycemicnonketotic coma)
Extremely high blood glucosedehydration
No ketosis
Common in
Elderly w/ Type 2
Dont realize thirstdo notdrink enough
Weight Loss Glucose Ketones
Breakdown of protein for energy
Type 1 diabetes Likely to be thinenergy lost
Type 2 overweight then gradualweight loss
Energy sources lostIn urine
Nursing Diagnosis: alterednutrition: less than body
requirements frequently appliesto person w/ Type 1 diabetes
Hypoglycemia
(insulin reaction/insulin shock)
Inappropriate management of diabetes
Too much insulin
Strenuous physical activity
Skipped/delayed meals
Not enough food
Vomiting
Severe diarrhea
Mental confusion and shakiness
Make it difficult for diabetic to takeaction to correct
The Nursing Diagnosis
Altered nutrition: less than bodyrequirements
Symptoms Hunger
Headache
Sweating
Shakiness
Nervousness
Confusion
Disorientation
Slurred speech
Chronic Complicationsof Diabetes
Chronic hyperglycemia
Damages blood vessels & nerves even before diagnosis
Circulation not good Nerve function
Risk of infections
The Nursing Diagnosis
Risk of infection
Syndrome X
The combination of insulinresistance, hyperinsulinemia,obesity, hypertension, elevatedLDL and triglycerides, andreduced HDL that is frequentlyassociated with type 2 diabetesand cardiovascular disease.Also called Insulin-resistancesyndrome and metabolicsyndrome
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Cardiovascular diseases
Atherosclerosis
Develops early
Progresses rapidly
80% of diabetics die from CVD
Especially heart attacks
Small Blood Vessel Disorders
Capillaries
Nephropathy (loss of kidney function)
Retinopathy (retinal degeneration/vision loss
85%affected
Neuropathy
Nerve tissue deteriorates
Painful prickling
Loss of sensation
Injuries often go unnoticedinfection gangreneamputations of limbs
Toes/feet/legs
Gastric emptying delayed
Nausea
Vomiting
Weight loss
Irregular nutrient control
Treatment ofDiabetes Mellitus
Diagnosis
Devastating
Overwhelming
Change Lifestyle
To control blood glucosesuccessfully, the personmust master the complextask of coordinating diet,physical activity, and
medications.
Treatment Goals
Maintain blood glucosewithin fairly normalrange,
blood lipids optimal
blood pressure controlled
Reduces risk of onset andprogression by 50%
Nephropathy
Retinopathy
Neuropathy
Treatment Plans
Lifestyle changes
Assess and monitor
Diet
Physical activity Meds
Health status
Diabetes education
Medical Nutrition Therapy
for Diabetes
Diet same as for all healthy peopleControlling
Carbohydrates hypo/hyperglycemia
Protein Kidney function
Fats CVD
Coordinate diet w/
Meds
Physical activity
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EnergyAmount
Healthy/realistic bodyweight
Growth children/pregnancy
Type 2 diabetics
Weight loss
10-20 lbs.
Helps w/
Insulin resistance
Blood lipids
Blood pressure
Moderate kcalrestriction
Protein
10-20% of total kcal
Adequate but not excessive helps delay onset orprogression of kidney disease
0.8 g/kg of body weight
Same as RDA for healthypeople
Carbohydrates
Throughout day
Consistent amounts
Affect blood glucose most
Greatest effect on bloodglucose about 1 hour aftereaten
45-60% total kcal
Regular physical activity
Attention to meds
Consistent carbs
Too much hyperglycemia
Too little hypoglycemia
Evening snack
Sustains glucose through night
Frequent hypoglycemia treatsw/ carbs weight gain
Safe amount of glucose
ComplexCarbohydratesVersus SimpleSugars
Encourage Whole-grain breads and
cereals
Legumes
Fruits
Vegetables
Provide Fiber
Vitamins
Minerals
Concentrated sweets
Excluded In past Now - in moderation
Artificial sweeteners Minimal calories
Can be used in place ofsugar
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Fat
If blood lipids Ok
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Treating Hypoglycemia
10-15 g carb w/ notice of symptoms
If on oral agents that interfere w/digestion of sucroseneed glucose
If notany readily available andeasily eaten carb OK
See margin p. 473
Avoid foods w/ fat interferes w/absorption of carb
Check blood glucose within15-20 min.
If risen to acceptablelevelOK
If not - additional 15-20 g ofcarb
Recheck
Continue until blood glucoseto acceptable range
Advise carrying convenientcarb source w/ them
Nocturnal hypoglycemia
People prone to nocturnalhypoglycemia
Wake up during night
Check blood glucose
Snack at bedtime
May
Plan strenuous activitiesfor earlier in day
Reduce insulin dose afterevening activity
both
Hypoglycemia
If severe Disorientation
Many dont recognize
Unable to swallow
IV glucose or Hormone glucagon
Without treatmentshock and death
Enteral and Parental Formulas
Indications same as for other people
Adjustments for carbs formulas
provide Adjust insulin
Formula may need to be more lipidsand less carbohydrate
Specially designed formulas an option
Meal Planning Strategies
Several approachesIndividual
Exchange Lists
Sorts food into 3 groupsProportions of carb, fat,and protein
Carb group Starches Fruit Milk and some milk
products Other carbs Vegetables
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Fat Group Butter
Margarine
Oil salad dressing
Nuts Olives
Bacon
Avocados
Coconut
Cream cheese
Meat and meatsubstitutes group
High protein foods
Fig. 20-2 p. 475examples
Strict portion sizes All foods in exchange
list about same # kcaland nutrients
Any food on listexchanged foranother
HOWTO box p. 477-480
Exchange system a tool
Fat sources and types
Fat free milk - milk
Whole fat exchange
Foods in meat list
Separated into fat categories
Low.
Medium
and
High fat
Carbohydrate counting
Learn to eat consistentamounts of carbohydrates
Monitor blood glucose andkeep records
HOWTO box p. 481
Client must learn to
Plan healthy meals
Eat consistent amounts offoods
Maintain healthy body weight
PhysicalActivity
Carefully evaluate
Appropriate
Type
Amount
Type 2 diabetes
Regular physical activity
Improves blood glucosecontrol
Helps w/ weight loss
Improves blood lipids
blood pressure
Physical Activity andBlood Glucose Levels
Check blood glucose
Before
After
Postpone if
Too low 300 mg/100 ml
Can levels evenhigher
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Physical Activity and FoodIntake
Adequate hydration
Before
During
On insulin Eat
Before
During
After Carbs especially important
Amount depends on
Type
Duration
Individual responses to
Blood testing results
exercise
Drug Therapyfor Diabetes
Type I
Need insulin
Type 2
Sometimes w/out meds
Exercise
Diet
Oral meds
Insulin
Oral Antidiabetic Agents
Many different ones available
Some
stimulate release of insulin from betacells
reduce insulin resistance anddepress manufacture of glucose
reduce rate of complex carbohydrateand sucrose digestion and slow rateof absorption (must use glucose tomanage hypoglycemic episodes)
Insulin and Insulin Analogs
Different forms
Different timings
Rapid (regular)
Intermediate NPH and lente
Long acting ultra-lente
Insulin analog lispro
Acts more quickly
Short duration
risk for hypoglycemia
Insulin and Food Intake
Normally baseline amount w/ moreafter meals
Type I diabetes
NHP (intermediate acting) tomeet baseline needs
Regular (rapid-acting) toprocess nutrients after a meal
Type II diabetes
Insulin alone
Or
Combination of oral and insulin
Insulin and Physical Activity
Insulin taken
More than an hour before
Exercise and temperature
Speed blood flow rate of insulin absorption
Hypoglycemia likely
Reducing insulin dose 30-50%can prevent
[also care w/ injection site andmuscles used in exercise]
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Pancreas Transplants
For those who have serious
trouble managing
Successful
Combined w/ kidney transplant
Can eliminate need for insulinand dialysis
Monitoring
DiabetesManagement
Blood glucose meters
During medical assessmentslook at management makesuggestions
Even when diligenthypoglycemia andhyperglycemia at times
Table 10-6 p. 485
Glycated Hemoglobin
Physicians monitor
Evaluate % of glycated Hb (GHb)
Blood glucose glucoseattaches to amino acids on Hbmolecules
Reflects blood glucosemanagement over past 2-3 months
Urinary Ketones
Monitor
Especially during illness
Predisposed to ketosis andcoma
Other Measures
Weight
Blood lipids
Blood pressure
Reflexes
Diabetes Management
throughout Life
Diabetes Management inChildhood
Energy and nutrient needschange
Difficult w/ children Appetites
Activity
Teens
Difficult when trying tobe the same
New rules
Can manage itthemselves
Meal Plans
Flexible, balanced meals
Snacks
Variety of foods
Carb counting
Snacks at bedtime
Do not force to finish meal
Encourage not to skip meals
Concentrated sweets allowed withinhealthy diet
Meals at about same time each day
Can eat same foods as rest of family
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Family Lifestyles
Incorporate prescribed dietinto existing lifestyle
Child 3 meals/day 2-3 snacks (between meals
and at bedtime)
Vary meals and snacks toprevent boredom
Avoid labeling goodfoods/bad foods
Diabetes Managementin Pregnancy
Pregnancy Elevates blood sugar
Alters insulin resistance
Cells become insulinresistant
Levels of hormonesantagonize
Health Risks Associated withDiabetes During Pregnancy
Uncontrolled Type I or 2
Risk of spontaneous abortion
Macrosomic infant
High blood glucoseoverfeeds
Fetus must also make extrainsulin to handle
After birth hypoglycemic
Important to control diabetesduring pregnancy
Gestational Diabetes
Most common pregnancycomplication
Will screen for at 24-28 weeksunless
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Medical Nutrition Therapy
Individualized diet Additional needs of pregnancy
Insulin therapy
Adequate but not excessive kcals
Carbohydrates moderately restricted
40-45% of total kcal
Frequent small meals
Diabetes ManagementLater in Life
Elderly
Special problems in dealing w/ diabetes
Risk for hyper- and hypoglycemia
Reduced appetite
thirst regulation
Altered organ function
Depression
Mental deterioration
Multiple meds
Medical conditions that complicate
Blood Glucose Control
Type 2
May advance until insulinnecessary
Overwhelming
Vision loss can affect
Drawing meds
Giving injections
Monitoring blood glucose
May make it impossible tolive independently
Financial and SocialConsiderations
Financial
Medication
Supplies
Dr.s visits
Health and nutritionalstatus may deteriorate
Social interaction may
Depression possible
Health care professionalsmust help elderly findsolutions to theseproblems
See Nutrition AssessmentChecklist for People withDiabetes