medical nutrition therapy for diabetes mellitus and hypoglycemia of nondiabetic origin

Medical Nutrition Therapy for Diabetes Mellitus and Hypoglycemia of Nondiabetic Origin

Medical Nutrition Therapy for Diabetes Mellitus and Hypoglycemia of Nondiabetic Origin

Chapter 33Chapter 33

© 2004, 2002 Elsevier Inc. All rights reserved.

Diabetes MellitusDefinitionDiabetes MellitusDefinition

A group of diseases characterized by high blood glucose concentrations resulting from defects in insulin secretion, insulin action, or both

A group of diseases characterized by high blood glucose concentrations resulting from defects in insulin secretion, insulin action, or both


Diabetes and PrediabetesTypesDiabetes and PrediabetesTypes

Type 1 (formerly IDDM, type I)

Type 2 (formerly NIDDM, type II)

Gestational diabetes mellitus (GDM)

Prediabetes (impaired glucose homeostasis)

Other specific types

Type 1 (formerly IDDM, type I)

Type 2 (formerly NIDDM, type II)

Gestational diabetes mellitus (GDM)

Prediabetes (impaired glucose homeostasis)

Other specific types


DiabetesType 1DiabetesType 1

Two forms

– Immune mediated—beta cells destroyed by autoimmune process

– Idiopathic—cause of beta cell function loss unknown

Two forms

– Immune mediated—beta cells destroyed by autoimmune process

– Idiopathic—cause of beta cell function loss unknown


DiabetesType 2DiabetesType 2

Most common form of diabetes accounting for 90% to 95% of diagnosed cases

Combination of insulin resistance and beta cell failure (insulin deficiency)

Progressive disease

Most common form of diabetes accounting for 90% to 95% of diagnosed cases

Combination of insulin resistance and beta cell failure (insulin deficiency)

Progressive disease


Prediabetes(Impaired Glucose Homeostasis)Prediabetes(Impaired Glucose Homeostasis)

Two forms

– Impaired fasting glucose (IFG)— fasting plasma glucose(FPG) above normal

– Impaired glucose tolerance (IGT)— plasma glucose elevated after 75 g glucose load

Two forms

– Impaired fasting glucose (IFG)— fasting plasma glucose(FPG) above normal

– Impaired glucose tolerance (IGT)— plasma glucose elevated after 75 g glucose load


Gestational Diabetes Mellitus(GDM)Gestational Diabetes Mellitus(GDM)

Glucose intolerance with onset or first recognition during pregnancy

Glucose intolerance with onset or first recognition during pregnancy


Diabetes—SymptomsDiabetes—Symptoms

General

Hyperglycemia

Glycosuria

Polyuria

Polydipsia

Dehydration

General

Hyperglycemia

Glycosuria

Polyuria

Polydipsia

Dehydration

Type 1

Ketonuria

Acetone breath

Acidosis

Weight loss

Polyphagia

Type 1

Ketonuria

Acetone breath

Acidosis

Weight loss

Polyphagia


Type 1 Diabetes—Cause Type 1 Diabetes—Cause

Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000.


Type 1 Diabetes—PathophysiologyType 1 Diabetes—Pathophysiology



Type 1 Diabetes—Medical and Nutritional ManagementType 1 Diabetes—Medical and Nutritional Management

Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000. Updated by Marion J. Franz, 2002.


Metabolic SyndromeMetabolic Syndrome

Characteristics

Insulin resistance

Compensatory hyperinsulinemia

Abdominal obesity

Dyslipidemia (elevated TG, low HDL)

Hypertension

Risk factor for cardiovascular disease and glucose intolerance

Characteristics

Insulin resistance

Compensatory hyperinsulinemia

Abdominal obesity

Dyslipidemia (elevated TG, low HDL)

Hypertension

Risk factor for cardiovascular disease and glucose intolerance


Type 2 Diabetes—Cause Type 2 Diabetes—Cause



Type 2 Diabetes—Pathophysiology Type 2 Diabetes—Pathophysiology



Type 2 Diabetes—Medical and Nutritional ManagementType 2 Diabetes—Medical and Nutritional Management

Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000. Updated by Marion J. Franz, 2002.


Methods of DiagnosisMethods of Diagnosis

Fasting plasma glucose (FPG)

Casual plasma glucose (any time of day)

Oral glucose tolerance test (OGTT)

Fasting plasma glucose (FPG)

Casual plasma glucose (any time of day)

Oral glucose tolerance test (OGTT)


Criteria for DiagnosisCriteria for Diagnosis

FPG mg/dl

OGTT 2 hr mg/dl

Casual PG mg/dl

Normal <110 <140

Pre- diabetes

>110 and < 126

>140 and <200

Diabetes

>126

>200

>200 + symptoms

FPG mg/dl

OGTT 2 hr mg/dl

Casual PG mg/dl

Normal <110 <140

Pre- diabetes

>110 and < 126

>140 and <200

Diabetes

>126

>200

>200 + symptoms


Who Should Be Screened for DM?Who Should Be Screened for DM?

Persons >45 years; repeat every 3 years

Younger age; screened more frequently

Overweight (BMI >25)

First-degree relative with diabetes

High-risk ethnic population

Delivered baby >9 lb or diagnosed GDM

Hypertensive

HDL <35 mg/dl or TG >200

Prediabetes

Polycystic ovary syndrome

Persons >45 years; repeat every 3 years

Younger age; screened more frequently

Overweight (BMI >25)

First-degree relative with diabetes

High-risk ethnic population

Delivered baby >9 lb or diagnosed GDM

Hypertensive

HDL <35 mg/dl or TG >200

Prediabetes

Polycystic ovary syndrome


Pathophysiologic Complications of Type 1 Diabetes MellitusPathophysiologic Complications of Type 1 Diabetes Mellitus

Ketoacidosis

Macrovascular disease

Microvascular disease

—Retinopathy

—Nephropathy

Neuropathy

Ketoacidosis

Macrovascular disease

Microvascular disease

—Retinopathy

—Nephropathy

Neuropathy


Pathophysiologic Complications of Type 2 Diabetes MellitusPathophysiologic Complications of Type 2 Diabetes Mellitus

Abnormal pattern of insulin secretion and action

Insulin resistance causing decreased cellular uptake of glucose

Increased gluconeogenesis and hepatic glucose release

Abnormal pattern of insulin secretion and action

Insulin resistance causing decreased cellular uptake of glucose

Increased gluconeogenesis and hepatic glucose release


Insulin Counterregulatory HormonesInsulin Counterregulatory Hormones

Glucagon

Epinephrine (adrenaline)

Norepinephrine

Cortisol

Growth hormone

Glucagon

Epinephrine (adrenaline)

Norepinephrine

Cortisol

Growth hormone


Diabetes—Treatment GoalsDiabetes—Treatment Goals

FPG 90—130 mg/dl

Hemoglobin A1c <7%

FPG 90—130 mg/dl

Hemoglobin A1c <7%


Oral Glucose-Lowering MedicationsOral Glucose-Lowering Medications

Drugs, administered orally, that are used to control or lower blood glucose levels, including first- and second-generation sulfonylureas, nonsulfonylurea secretagogues, biguanides, alpha-glucosidase inhibitors, and thiazolidinediones

Drugs, administered orally, that are used to control or lower blood glucose levels, including first- and second-generation sulfonylureas, nonsulfonylurea secretagogues, biguanides, alpha-glucosidase inhibitors, and thiazolidinediones


Oral Glucose-Lowering Medications—cont’dOral Glucose-Lowering Medications—cont’d Sulfonylureas

—Stimulate insulin secretion from beta cells Meglitinide

—Stimulates insulin secretion from beta cells Biguanide

—Decreases hepatic glucose production and increases insulin secretion

Thiazolidinediones—Improve peripheral insulin sensitivity

Alpha glucosidase inhibitor—Delays carbohydrate absorption

Sulfonylureas—Stimulate insulin secretion from beta cells

Meglitinide—Stimulates insulin secretion from beta cells

Biguanide—Decreases hepatic glucose production and increases

insulin secretion Thiazolidinediones

—Improve peripheral insulin sensitivity Alpha glucosidase inhibitor

—Delays carbohydrate absorption


Action Times of Human Insulin RegimensAction Times of Human Insulin Regimens

Insulin Onset Peak Duration

Rapid acting

(Lispro, Aspart)

<15 min 0.5–1.5 hr 2–4 hr

Short acting

(Regular)

0.5–1 hr 2–3 hr 3–6 hr

Intermediate

(NPH)

2–4 hr 6–10 hr 10–16 hr

Long acting

(Ultralente)

6–10 hr 10–16 hr 18–20 hr

Mixtures 0.5–1 hr Dual 10–16 hr


Estimating Minimum Energy Requirements for YouthEstimating Minimum Energy Requirements for Youth

Base energy requirements on food and nutrition assessment

Validate energy needs

Toddlers

Base energy requirements on food and nutrition assessment

Validate energy needs

Toddlers


Diabetes PreventionDiabetes Prevention

Moderate weight loss (5%–7% body weight)

Regular physical activity

Low-fat diet (30% of energy intake)

Structured programs with regular participant contact

Moderate weight loss (5%–7% body weight)

Regular physical activity

Low-fat diet (30% of energy intake)

Structured programs with regular participant contact


Types of HypoglycemiaTypes of Hypoglycemia

Postprandial hypoglycemia

Alimentary hyperinsulinemia

Idiopathic reactive hypoglycemia

Fasting hypoglycemia

Factitious hypoglycemia

Postprandial hypoglycemia

Alimentary hyperinsulinemia

Idiopathic reactive hypoglycemia

Fasting hypoglycemia

Factitious hypoglycemia


Goals of Medical Nutrition Therapy for DiabetesGoals of Medical Nutrition Therapy for Diabetes Maintenance of as near normal BG levels as

possible, by balancing food, medication, and physical activity

Achievement of optimal serum lipid levels

Provision of adequate calories for maintaining or attaining reasonable weight in adults, normal growth/development in children and adolescents, increased metabolic needs in pregnancy and lactation, or recovery from catabolic illnesses

Maintenance of as near normal BG levels as possible, by balancing food, medication, and physical activity

Achievement of optimal serum lipid levels

Provision of adequate calories for maintaining or attaining reasonable weight in adults, normal growth/development in children and adolescents, increased metabolic needs in pregnancy and lactation, or recovery from catabolic illnesses


Goals of Medical Nutrition Therapy for Diabetes—cont’dGoals of Medical Nutrition Therapy for Diabetes—cont’d Prevention and treatment of the acute or

chronic complications of diabetes

Improvement of overall health through optimal nutrition using the Dietary Guidelines for Americans and the Food Guide Pyramid

Prevention and treatment of the acute or chronic complications of diabetes

Improvement of overall health through optimal nutrition using the Dietary Guidelines for Americans and the Food Guide Pyramid


Basic Strategies for Type 1 DiabetesBasic Strategies for Type 1 Diabetes

Meal plan should be based on assessment of patients usual food intake.

Integrate insulin therapy into the usual eating and exercise patterns.

Conventional therapy requires eating at consistent times synchronized with the action of insulin.

Intensified therapy allows more flexibility in timing and amount of food eaten.

Meal plan should be based on assessment of patients usual food intake.

Integrate insulin therapy into the usual eating and exercise patterns.

Conventional therapy requires eating at consistent times synchronized with the action of insulin.

Intensified therapy allows more flexibility in timing and amount of food eaten.


Basic Strategies for Type 2 DiabetesBasic Strategies for Type 2 Diabetes

Encourage weight loss.

Moderate calorie restriction (250–500 kcal/day less) is associated with improved control independent of weight loss.

Spread nutrient intake, especially carbohydrate (CHO) throughout the day.

Encourage physical activity.

Decrease fat intake.

Monitor BG, and add medications if needed.

Encourage weight loss.

Moderate calorie restriction (250–500 kcal/day less) is associated with improved control independent of weight loss.

Spread nutrient intake, especially carbohydrate (CHO) throughout the day.

Encourage physical activity.

Decrease fat intake.

Monitor BG, and add medications if needed.


Food Guide PyramidFood Guide Pyramid

Use basic guide

Use diabetes-specific guide

Use basic guide

Use diabetes-specific guide


Recommendations for Weight ManagementRecommendations for Weight Management

Make permanent changes in eating behavior.

Eat regularly.

Slow, gradual weight loss is best.

Choose lower-fat foods.

Incorporate regular physical activity.

Make permanent changes in eating behavior.

Eat regularly.

Slow, gradual weight loss is best.

Choose lower-fat foods.

Incorporate regular physical activity.


ProteinProtein

Provides 4 kcal/g

10% to 20% of total kcal

0.8 g/kg (note: this is the RDA for the general population) is recommended for clients with microalbuminuria. This is feasible with regular foods.

Once GFR begins to fall, some recommend 0.6 g/kg; this will likely require special low-protein foods and nutrition deficiency is possible.

Animal vs plant

Provides 4 kcal/g

10% to 20% of total kcal

0.8 g/kg (note: this is the RDA for the general population) is recommended for clients with microalbuminuria. This is feasible with regular foods.

Once GFR begins to fall, some recommend 0.6 g/kg; this will likely require special low-protein foods and nutrition deficiency is possible.

Animal vs plant


FatFat

Provides 9 kcal/g

General recommendation of <30% of total kcal and saturated fat <10% of total calories applies to people with DM who have normal lipid levels and a reasonable body weight.

If client is obese or has elevated lipid levels, further reduction combined with physical activity should be considered.

If LDL is primary problem, use the NCEP Step II diet (saturated fat <7% of total calories).

Provides 9 kcal/g

General recommendation of <30% of total kcal and saturated fat <10% of total calories applies to people with DM who have normal lipid levels and a reasonable body weight.

If client is obese or has elevated lipid levels, further reduction combined with physical activity should be considered.

If LDL is primary problem, use the NCEP Step II diet (saturated fat <7% of total calories).


CarbohydrateCarbohydrate

Provides 4 kcal/g

Total carbohydrate consumed is more important than the source of the carbohydrate.

Daily total and distribution should be individualized and based on each client’s habits and blood glucose and lipid goals.

Provides 4 kcal/g

Total carbohydrate consumed is more important than the source of the carbohydrate.

Daily total and distribution should be individualized and based on each client’s habits and blood glucose and lipid goals.


Action of Insulin on Carbohydrate, Protein, and Fat MetabolismAction of Insulin on Carbohydrate, Protein, and Fat Metabolism


SucroseSucrose

Numerous studies in which sucrose was substituted for starch found no adverse effect on glycemia.

Sucrose and sucrose-containing foods must be substituted for other carbohydrates and not simply added to the meal plan.

Still important to recommend caution because foods containing sucrose generally contain minor amounts of vitamins and minerals and tend to be higher in fat

Numerous studies in which sucrose was substituted for starch found no adverse effect on glycemia.

Sucrose and sucrose-containing foods must be substituted for other carbohydrates and not simply added to the meal plan.

Still important to recommend caution because foods containing sucrose generally contain minor amounts of vitamins and minerals and tend to be higher in fat


Nutritive SweetenersNutritive Sweeteners

Include fructose, honey, corn syrup,molasses, fruit juice, dextrose, maltose, mannitol, sorbitol, xylitol, and hydrogenated starch hydrosylates as well as sucrose

Research has shown no significant advantage or disadvantage of any of these over sucrose.

Large amounts of fructose may increase cholesterol levels.

Sugar alcohols in large amounts cause osmotic diarrhea.

Include fructose, honey, corn syrup,molasses, fruit juice, dextrose, maltose, mannitol, sorbitol, xylitol, and hydrogenated starch hydrosylates as well as sucrose

Research has shown no significant advantage or disadvantage of any of these over sucrose.

Large amounts of fructose may increase cholesterol levels.

Sugar alcohols in large amounts cause osmotic diarrhea.


Nonnutritive SweetenersNonnutritive Sweeteners

Include aspartame, acesulfame K, sucralose, and saccharin

All can be safely used by people with diabetes mellitus.

Average intake of aspartame is 2 to 4 mg/kg/day, whereas the ADI is 50 mg/kg/day

ADI of acesulfame K is 15 mg/kg, which is the equivalent of a 60 kg person eating 36 teaspoons of sugar daily

Include aspartame, acesulfame K, sucralose, and saccharin

All can be safely used by people with diabetes mellitus.

Average intake of aspartame is 2 to 4 mg/kg/day, whereas the ADI is 50 mg/kg/day

ADI of acesulfame K is 15 mg/kg, which is the equivalent of a 60 kg person eating 36 teaspoons of sugar daily


FiberFiber

Same recommendation as the general public—20 to 35 g/day. Increase gradually and make sure they have adequate water intake.

Beneficial in maintaining normal GI function and treating or preventing several benign GI disorders and colon cancer

Although selected soluble fibers are capable of delaying glucose absorption, the effect on glycemia is probably insignificant.

Large amounts of soluble fiber may have a beneficial effect on serum lipids

Provide satiety value

Same recommendation as the general public—20 to 35 g/day. Increase gradually and make sure they have adequate water intake.

Beneficial in maintaining normal GI function and treating or preventing several benign GI disorders and colon cancer

Although selected soluble fibers are capable of delaying glucose absorption, the effect on glycemia is probably insignificant.

Large amounts of soluble fiber may have a beneficial effect on serum lipids

Provide satiety value


SodiumSodium

Association between hypertension (HTN) and both types of diabetes mellitus (DM)

Same intake as general population is recommended for otherwise healthy people with DM—less than 3000 mg/day

For people with mild HTN and diabetes—should have less than 2400 mg/day

For people with more serious HTN or edematous clients with nephropathy recommend 2000 mg/day or less

Association between hypertension (HTN) and both types of diabetes mellitus (DM)

Same intake as general population is recommended for otherwise healthy people with DM—less than 3000 mg/day

For people with mild HTN and diabetes—should have less than 2400 mg/day

For people with more serious HTN or edematous clients with nephropathy recommend 2000 mg/day or less


Lipid GoalsLipid Goals

Cholesterol <200 mg/dl

LDL cholesterol <100 mg/dl

HDL cholesterol

Men >45 mg/dl

Women >55 mg/dl

Triglycerides <150 mg/dl

Cholesterol <200 mg/dl

LDL cholesterol <100 mg/dl

HDL cholesterol

Men >45 mg/dl

Women >55 mg/dl

Triglycerides <150 mg/dl


Blood Pressure GoalsBlood Pressure Goals

Systolic <130 mm Hg

Diastolic <80 mm Hg

Systolic <130 mm Hg

Diastolic <80 mm Hg


AlcoholAlcohol

In a fasting state ETOH may produce hypoglycemia, and this effect can persist for 8 to 12 hours after the last drink.

Can’t be converted to glucose; inhibits gluconeogenesis

In a fasting state ETOH may produce hypoglycemia, and this effect can persist for 8 to 12 hours after the last drink.

Can’t be converted to glucose; inhibits gluconeogenesis


Alcohol Guidelines for Insulin UsersAlcohol Guidelines for Insulin Users

Limit to no more than two drinks per day

Drink only with food

Do not cut back on the amount of food eaten..

Abstain if history of ETOH abuse and during pregnancy or lactation or if there are possible interactions with other medications

Limit to no more than two drinks per day

Drink only with food

Do not cut back on the amount of food eaten..

Abstain if history of ETOH abuse and during pregnancy or lactation or if there are possible interactions with other medications


Alcohol Guidelines for Noninsulin UsersAlcohol Guidelines for Noninsulin Users

Substitute for fat calories

Limit to promote weight loss or maintenance

Limit if triglycerides are elevated

Abstain if history of ETOH abuse and during pregnancy or lactation, or if there are possible interactions with other medications

Substitute for fat calories

Limit to promote weight loss or maintenance

Limit if triglycerides are elevated

Abstain if history of ETOH abuse and during pregnancy or lactation, or if there are possible interactions with other medications


MicronutrientsMicronutrients

Vitamin/mineral needs of people with diabetes who are healthy appear to be adequately met by the RDAs.

Those who may need supplementation include those on extreme weight-reducing diets, strict vegetarians, the elderly, pregnant or lactating women, clients with malabsorption disorders, congestive heart failure (CHF) or myocardial infarction (MI)

Chromium and magnesium are beneficial only if the client is deficient.

Vitamin/mineral needs of people with diabetes who are healthy appear to be adequately met by the RDAs.

Those who may need supplementation include those on extreme weight-reducing diets, strict vegetarians, the elderly, pregnant or lactating women, clients with malabsorption disorders, congestive heart failure (CHF) or myocardial infarction (MI)

Chromium and magnesium are beneficial only if the client is deficient.


Food Adjustments for Special SituationsFood Adjustments for Special Situations

Illness

Exercise

Hypoglycemia

Pregnancy

Ethnic or cultural differences

Illness

Exercise

Hypoglycemia

Pregnancy

Ethnic or cultural differences


Four-Pronged Approach to Diabetes Medical Nutrition TherapyFour-Pronged Approach to Diabetes Medical Nutrition Therapy

Comprehensive nutrition assessment

Set goals with the client

Nutrition intervention

Evaluation

Comprehensive nutrition assessment

Set goals with the client

Nutrition intervention

Evaluation


Nutrition InterventionNutrition Intervention

Dietary Guidelines for Americans

Guide to good eating

Food Guide Pyramid

The first step in diabetes meal planning

Healthy food choices

Healthy eating

Dietary Guidelines for Americans

Guide to good eating

Food Guide Pyramid

The first step in diabetes meal planning

Healthy food choices

Healthy eating

Single-topic diabetes resources

Individualized menus

Month of meals

Exchange lists for meal planning

CHO counting

Calorie counting

Fat counting

Single-topic diabetes resources

Individualized menus

Month of meals

Exchange lists for meal planning

CHO counting

Calorie counting

Fat counting

medical nutrition therapy for diabetes mellitus and hypoglycemia of nondiabetic origin

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