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Disturbance in Glucose Utilization

Diabetes Mellitus- Gestational Diabetes- Impaired Glucose

Tolerance- Hypoglycemia

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Diabetes Mellitus

There are two types of diabetes mellitus:

Type I, or insulin dependent (IDDM) Type II, or non-insulin dependent

(NIDDM)

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Gestational Diabetes

A temporary type of diabetes that occurs during pregnancy

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Impaired Glucose Tolerance

A higher than normal blood glucose level that is below the accepted value to diagnose diabetes

Diet therapy is essential for all types of disturbance in glucose utilization

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The Goals of Diet Therapy for Diabetes1. Attain and maintain desirable body weight.

2. Provide a normal growth rate in children and pregnant women.

3. Minimize glycosuria and keep the plasma glucose as near normal physiological range as possible.

4. Prevent and/or delay the development and/or progression of cardiovascular, renal, retinal, neurological, and other complications associated with diabetes.

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5. Modify the diet as necessary for complications of diabetes and for associated diseases

6. Improve the overall health of the patient by attaining and maintaining an optimal nutritional status.

7. Provide for each patient an individualized educational and follow-up program.

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Nutrition Guidelines

1. Type 1 diabetes:i. Take diet history usual pattern of food

intake and physical activity

ii. Develop an individualized meal plan and schedule of insulin therapy

iii. Emphasize the need for regular meal and snack schedule + SMBG

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iv. Synchronize food intake with the time of action of the insulin used, and teach patient to change dosage and time of administration to compensate for changes in the meal plan

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2. Type 2 diabetes:i. Take diet history usual pattern of

food intake and physical activity ii. Aim to reduce weightiii. Reduce fat intakeiv. Encourage physical activityv. Emphasize the need to control BG,

lipid levels and BP by dietary means, explaining how to do so

vi. Develop an individualized meal plan

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3. Diabetes in Pregnancy:A- Diabetic women who become pregnant:i. Intensive therapy is indicatedii. SMBG must be conductediii. Changing meal plan with advancing

pregnancy to maintain fatal growthiv. Restrict energy intake for obese

women (BMI > 30) v. Encourage physical activityv. Monitor urine for ketones

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B- GDMi. Provide adequate calories and nutrients to

promote normal fetal growth

ii. Plan meal times to maintain FBG at ≤ 95 mg/dl or 2h PPG at ≤ 120 mg/dl + SMBG

iii. Bed time snack may be recommended to reduce risk of hypoglycemia at night

iv. Restrict energy intake for obese women (BMI > 30)

v. Encourage physical activity

v. Monitor urine for ketones

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Dietary management of impaired glucose tolerance

1. Weight loss if needed

2. Avoidance of concentrated sweets and fats

3. Increase level of exercise

4. Increase intake of soluble fiber incase of hyper-triglyceridemia

Nutritional Management of DM

Meal planning: Balanced meals are essential Meals should include a source of

protein to slow digestion, and the increase in blood sugar

Complex carbohydrates are preferred, while simple sugars avoided

Carbohydrates should be divided carefully between meals and snacks

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Some Complications of Diabetes

Nutritional Management

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Insulin Shock or Insulin Reaction & Hypoglycemia Causes: More insulin is injected or more oral

hypoglycaemic agents are given than needed

Foods are omitted from diet Increased physical activity An error in insulin injection in relation

to exercise

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Symptoms: Blood glucose decreases below

acceptable level and patient sweats profusely

If not treated promptly the patient experiences :

Mental confusion and disorientation If untreated seizures occur followed by unconsciousness and Death

Prevention and Management

Avoid precipitating factors Recognize signs Test BG Correct hypoglycaemia If the patient is unconscious glucagon

injections must be given

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Coping with acute illness

Check BG and urine ketones often Consume 10-15 gm CHO every 1-2 hours When vomiting, diarrhea or fever present

consume liquids every 15-30 min. Notify health care provider if cannot

retain food for ≥ 4h.

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Other complications of DM

Heart disease- control fat & cholesterol intake

Kidney disease- control protein intake Diabetic retinopathy- control BG and

take anti-oxidants Neuropathy- control BG and take

vit.B1,B6 and B12 supplement

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Coping with gastroparesis

Give drugs to increase GI motility Correct hyperglycemia if present Keep record for food, BG, and

symptoms to fit insulin to peak absorption time

Use short and ultra-short insulin Decrease fat intake

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Decrease intake of high fiber food Give small frequent meals Chew well Maintain upright posture for 30-60 min

after meal

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Role of the nurse in nutritional management of diabetes

1. Review previous history and diet2. Give positive verbal reinforcement for

any attempt at control3. Identify areas of strength for positive

reinforcement and areas of need for referral or personal assistance

4. Assess the patient’s knowledge about his/her condition, and explain appropriate action in various situations

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Reactive Hypoglycaemia

Postprandial Second most common type of

hypoglycaemia Caused by exaggerated insulin release

following a meal leading to transient hypoglycaemia.

Glucose returns to normal without food.

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Dietary management of reactive hypoglycemia

1. Limit the intake of simple sugars, and conc. Sweets

2. Emphasize complex carbohydrates3. Eat small frequent meals and snacks (every 2

to 3 hours)4. Include a protein source with meals and

snacks5. Restrict intake of caffeine

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How to approximate the individual dietary needs

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Factors to consider:

i. Weight and height

ii. Caloric needs

iii. Division into protein, carbohydrate and fat

iv. Division into meals and snacks

v. Limitations (modifications for special condition)

vi. Need for insulin

vii. Individual food habits

viii. Family food budget

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Weight and height

BuildWomenMenChildren

MediumAllow 100 Ib. for first 5 ft. of height, plus 5 Ib. for each additional inch

Allow 106 Ib. for first 5 ft. of height, plus 6 Ib. for each additional inch

Chart growth pattern on graph (Wetzel, Lowa, or Stuart) every 3-6 months

SmallSubtract 10%Subtract 10%

LargeAdd 10%Add 10%

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Determination of caloric needs

For adults1. Basal calories equals desirable body weight

(Ib.) x 10, or (Kgx 22) 2. Add activity caloriesa. Sedentary equals desirable body weight (Ib.)

x 3, or ( Kg x 6.6)b. Moderate equals desirable body weight (Ib.)

x 5, or (Kg x11)c. Strenuous equals desirable body weight (Ib.)

x 10, or (Kgx22)

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3. Add calories for indicated weight gain, growth (pregnant women), or lactation

4. Subtract calories for indicated weight loss

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For children1. Children vary markedly in their caloric

needs depending on rate of growth and level of activity

2. Estimate caloric requirement from chart of Recommended Daily Dietary Allowances

3. Adjust caloric intake as needed to maintain normal rate of growth

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Determination of grams of protein, carbohydrate and fat

a. Protein: 20% of total calories for growing children and pregnant women, minimum of 0.5 gm per Ib.(1.1 gm/Kg)desirable body weight for other adults

b. Carbohydrate: from 50-70% of non-protein calories

c. Fat: from 30-50% of non-protein calories

Example for diet order of 2000 kcal /day Protein: 2000x0.15=300 kcal ÷4(kcal/g)=75g

Carbohydrate: 2000x0.6=1200 kcal ÷ 4(kcal/g)=300g

Fat: 2000x0.25=500 kcal ÷ 9(kcal/g)=55g

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Suggested division into meals and snacks

a. Meals usually contain 2/10 to 4/10 of the calories and carbohydrate, and

snacks usually contain 1/10 of the calories and carbohydrate

b. In the non-insulin dependent individual, food is usually divided into three meals per day.

In the insulin dependent individual, food is usually divided into three meals and a bedtime snack and occasionally a mid-afternoon and/or mid-morning snack, depending on plasma glucose levels

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Limitations (modifications for special conditions)

a. Protein

b. Saturated fat and/or cholesterol

c. Sodium

d. Potassium

e. other

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The GI Factor

The increase in the area under the blood glucose curve after the ingestion of 50 gm of carbohydrate in the test food compared to the area under the curve when 50 gm of glucose or white bread is taken

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