13/10/2019
1
2
DIET THERAPY FOR DIABETES MELLITUS
DIABETES MELLITUS IS A METABOLIC DISORDER THAT CAN STRIKE AT ANY AGE. IT AFFECTS NOT ONLY CARBOHYDRATE, BUT ALSO PROTEIN AND FAT UTILIZATION. IT IS A SERIOUS
HEALTH PROBLEM INDICATING A WORLDWIDE EPIDEMIC OF DIABETES
3
DIABETES IS THE LEADING CAUSE OF BLINDNESS, CARDIOVASCULAR DISEASE, LEG AND FOOT AMPUTATIONS AND KIDNEY FAILURE
WITH A HALLMARK OF HYPERGLYCEMIA
4
5
ABOUT 5 OUT OF 10 FILIPINOS ARE AT GREAT RISK OF DEVELOPING DIABETES .BOTH SEXES ARE EQUALLY AFFECTED;MAJORITY OF CASES ARE 40 YEARS ABOVE
DIET THERAPY FOR DIABETES MELLITUS
DIABETES MELLITUS IS A METABOLIC DISORDER THAT CAN STRIKE AT ANY AGE. IT AFFECTS NOT ONLY CARBOHYDRATE, BUT ALSO PROTEIN AND FAT UTILIZATION. IT IS A SERIOUS
HEALTH PROBLEM INDICATING A WORLDWIDE EPIDEMIC OF DIABETES
DIABETES IS THE LEADING CAUSE OF BLINDNESS, CARDIOVASCULAR DISEASE, LEG AND FOOT AMPUTATIONS AND KIDNEY FAILURE
WITH A HALLMARK OF HYPERGLYCEMIA
ABOUT 5 OUT OF 10 FILIPINOS ARE AT GREAT RISK OF DEVELOPING DIABETES .BOTH SEXES ARE EQUALLY AFFECTED;MAJORITY OF CASES ARE 40 YEARS ABOVE
TYPE 1 DIABETES
Juvenile onset DM
OCCURS IN YOUNG,LEAN PATIENTS AND IS CHARACTERIZED BY A MARKED INABILITY OF THE PATIENT
INABILITY OF THE PANCREAS TO SECRETE INSULIN AND DEPEND ON EXOGENOUS SOURCE OF INSULIN TO SUSTAIN THEIR LIVES.
THIS RESULTS IN ABNORMALLY HIGH LEVELS OF SUGAR IN THE BLOOD LEADING TO GRADUAL DETERIORATION OF SOME ORGANS AND A DECREASED LIFE SPAN OF AROUND 15 YEARS.
IN TURN,IT PRODUCES INCREASING AMOUNT OF ACIDIC COMPOUNDS CALLED KETONE BODIES.
FORMER NAMES: INSULIN DEPENDENT DIABETES MELLITUS AND JUVENILE ONSET DIABETES.
SIGNS AND SYMPOMTS:
THOSE IN THE TABLE PLUS
VERY DRY SKIN
SORES THATT ARE SLOW TO HEAL
MORE INFECTIONS THAN THE USUAL,
NAUSEA,
VOMITING,
13/10/2019
AND STOMACH PAINS
FEELING VERY TIRES MUCH OF THE TIME
TYPE 2
PREVIOUSLY CALLED ADULT ONSET DIABETES OR NON-INSULIN DEPENDENT DM
BODY’S INABILITY TO MAKE ENOUGH OR PROPERLY USE INSULIN
MOST COMMON FROM ACCOUNTING FOR 90-95% OF DIABETES
USUALLY APPEARS AFTER THE AGE OF 40,AND MANY TYPE 2 DIABETOCS ARE NOT AWARE THEY HAVE THE DISEASE UNTIL SEVERE COMPLICATIONS OCCUR
INCREASED WITH AGE AND OBESITY
MAJOR 3 METABOLIC DEFECTS THAT CONTRIBUTE TO HYPERGLYCEMIA TYPE 2
INCREASED GLOCUSE PRODUCTION IN THE LIVER
IMPAIRED INSULIN SECRETIONS BY THE PANCREATIC ISLES CELLS
INSULIN RESISTANCE IN SKELETAL MUSCLE
DRY MOUTH
NAUSEA
OCCASIONAL VOMITING
BLURRED VISION
FREQUENT INFECTIONS OF THE SKIN
UTI OR VAGINAL PROBLEMS WITH THEIR LIPID PROFILE
SERUM TRIGLYCERIDES AND LOW DENSITY LIPOPROTEIN ARE ELEVATED WHILE HIGH-DENSITY LIPOPROTIEN IS REDUCED, THIS IS WHY PATIENTS ARE PRONE TO ISCHEMIC VASCULAR DISEASE
GESTATIONAL DIABETES MELLITUS
IS A CARBOHYDRATE INTOLERANCE OF VARIABLE SEVERITY WITH ONSET OF RECOGNITION DURING THE PRESENT PREGNANCY
TYPICALLY DIAGNOSED DURING PRESENT PREGNANCY.3RD TRIMESTER AND IS RELATED
TO THE METABOLIC CHANGES DURING PREGNANCY
IT IS THE EFFECT OF INSULIN RESISTANCE. WHILE PREGNANT WOMAN PRODUCES PLENTIFUL AMOUNTS OF INSULIN, ITS ACTION IS PARTIALLY BLOCKED BY A VARIETY OF HORMONES BASE IN
THE PLACENTA SUCH AS ESTROGEN, CORTISOL, AND HUMAN PLACENTAL LACTOGEN. THIS CONTRA-INSULIN EFFECT TAKES PLACE TO ABOT 20-24 WEEKS.THE LARGER THE PLACENTA
,
13/10/2019
,
,
.T
GROWS THE MORE HORMONES ARE PRODUCED, THUS THE GREATER THE INSULIN RESISTANCE
-
20-24
.T
3
2
4
1 PREGNANT WOMEN WITH A FAMILY HISTORY OF DIABETES, HAVING GIVEN BIRTH PREVIOUSLY TO A VERY LARGE INFANT, A STILLBIRTH OR A CHILD WITH BIRTH DEFECT, AND HAVING TOO
MUCH AMNIOTIC FLUID ARE THOSE WHO ARE LIABLE TO DEVELOP
MACROSOMIA AND HYPOGLYCEMIA (AFTER BIRTH).
GDM. GESTATIONAL DIABETES IS USUALLY ASYMPTOMATIC BUT CONTROLLED BLOOD SUGAR MAY LEAD TO INFANT
METABOLISM IN DIABETES MELLITUS
FAT METABOLISM. FATTY ACID SYNTHESIS IN DM DECREASES RESULTING IN LIPOGENESIS (FAT FORMATION) WHILE FATTY OXIDATION INCREASE LIPOLYSIS (FAT BREAKDOWN). GLYCOGEN
STORES OF THE LIVER ARE DEPLETED WITH THE FAILURE TO SYNTHESIZE GLYCOGEN AND TO UTILIZE GLUCOSE. IN SUCH CIRCUMSTANCE, THE METABOLIC NEEDS ARE MET BY BREAKING DOWN
OF LARGE QUANTITIES OF FATTY ACIDS. THE FATTY ACID RELEASE FROM THE ADIPOSE TISSUE AND AVAILABLE BY ABSORPTION IN THE INTESTINAL TRACT ARE OXIDIZED BY THE LIVER
RESULTING IN THE FORMATION OF ‘’KETONE BODIES’’ SUCH AS ACETOACETIC ACID, BETA-HYDROXYBUTYRIC ACID AND ACETONE, WHICH ACCUMULATE IN THE BLOOD, A CONDITION CALLED
KETOSIS. THE ACID BASE EQUILIBRIUM IS DISTURBED; ITS DEPLETION LEADS ULTIMATELY TO ACIDOSIS.
ROLE OF INSULIN – NORMALLY INSULIN SIGNALS THE BODY THAT IT HAS BEEN FED AND DIRECTS CELLULAR ACTIVITIES THAT FAVOR THE STORAGE OF PROTEIN, CARBOHYDRATEAND FAT.
SPECIFICALLY,INSULIN STIMULATES GLUCOSE UTILIZATION IN THE SKELETAL MUSCLES,HEART AND SOME OTHER TISSUES.IT ALSO INCREASE SKELETAL MUSCLE BLOOD FLOW WHICH DEPENDS
ON RELEASE OF NITRIC OXIDE BY THE ENDOTHELIUM OF THE MUSCULAR VESSELS;INCREASING BLOOD FLOW IN THE MUSCLES INCREASE GLUCOSE UTILIZATION.
CARBOHYDRATE METABOLISM-NORMALLY,BLOOD GLUCOSE CONCENTRATION IS REGULATED AT 54-108 MG/DL (3-6 MMOL/DL) ALTHOUGH MANY REFERENCE PLACE THE NORMAL BLOOD
SUGAR LEVEL IN A FASTING STATE IS FROM 70-110 MG/100ML.IN PATIENTS WITH UNCONTROLLABLE DIABETES, THERE IS AN ABNORMAL INCREASE IN BLOOD SUGAR LEVEL DUE TO THE
ABSENCE OF OR INEFFICIENT FUNCTIONING INSULIN.BLOOD GLUCOSE CANNOT BE OXIDIZED PROPERLY IN THE CELLS TO FURNISH ENERGY AND THEREFORE ACCUMULATES IN THE BLOOD.
(HYPERGLYCEMIA).WHEN THE BLOOD GLUCOSE LEVEL EXCEEDS THE RENAL THRESHOLD (ABOUT 160 TO 180 G PER 100 ML), GLYCOSURIA OCCURS RESULTING IN THE WASTAGE OF ENERGY.
PROTEIN METABOLISM. ACCELERATED BREAKDOWN OF TISSUE PROTEIN ALSO OCCURS IN UNCONTROLLED DM, WHICH ADDS TO THE GLUCOSE LEVEL OF BLOOD AND INCREASE THE AMOUNT
OF NITROGEN THAT MUST BE EXCRETED AS A RESULT OF DEAMINATION AND ITS EXCRETION IN THE URINE.
DIAGNOSTIC AND MONITORING TEST
FASTING BLOOD SUGAR TEST
GLUCOSE TOLERANCE TEST
MEASURE OF THE ABILITY OF THE PATIENT TO UTILIZE A SPECIFIC AMOUNT OF GLOCUSE.IT IS USED TO ESTABLISH A DIAGNOSIS OF DIABETES OR IMPAIRED GLUCOSE TOLERANCE IN
ASYMPTOMATIC INDIVIDUAL WHOSE
FBS IS BETWEEN 110 AND 140 MG/DL OF PLASMA
GLYCOSYLATES HEMOGLOBIN (HBA1C) TEST
PROVIDES A GOOD INDEX FOR MONITORING OVERALL DIABETES CONTROL AND THERAPEUTIC DECISIONS CAN BE BASED ON THIS VALUE WHEN THIS TEST DETERMINATION IS NOT AVAILABLE
,FASTING PLASMA GLUCOSE LEVELS (FPG) MAY BE USED TO IDENTIFY PATIENTS WITH UNCONTROLLED T YPE 2 DM AND INITIATE TIMELY INTENSIFICATION OF THERAPY TO AVOID LONGTERM COMPLICATIONS OF DIABETES
SELF-MONITORING BLOOD GLUCOSE (SMBG)
13/10/2019
ALLOWS
PERSONS WHO HAVE DIABETES TO MEASURE THEIR BLOOD GLUCOSE AT HOME, ADJUST TREATMENT REGIMENS AS NEEDED, AND ACHIEVE NEAR-NORMAL BLOOD GLUCOSE LEVELS.
THIS REDUCES MICROVASCULAR COMPLICATIONS OF DM.
MORE SENSITIVE THAN URINE TESTING BECAUSE BLOOD GLUCOSE LEVEL MUST EXCEED 180-MG/100 ML BEFORE GLUCOSE SPILL INTO URINE.
USE TO CONFIRM HYPOGLYCEMIA AND HYPERGLYCEMIA
HELP MAINTAIN BLOOD GLUCOSE LEVELS BETWEEN 70 AND 140 MG/100ML.
FASTING BLOOD SUGAR SHOULD BE BELOW 100 MG/DL AND POSTPRANDIAL (POST-MEAL SUGAR) BELOW 140 MG/DL
URINE EXAMINATION
USEFUL IN TESTING THE TOTAL VOLUME, SPECIFIC GRAVITY, GLUCOSE AND FATTY
ACIDS.
(+) GLYCOSURIA (EXCRETION OF GLUCOSE INTO THE URINE) SHOULD BE REGARDED AS EVIDENCE OF DIABETES
GLUCOSE CAN BE TESTED USING PAPER INDICATOR, PAPER STICK, ADDITION OF POWDER TO THE URINE, ADDING A TABLET TO URINE
CHECKED BEFORE MEALS AND BEDTIME
RECOMMENDED URINE COLLECTION IS THE DOUBLE VOID METHOD IN WHICH THE PATIENT VOIDS THE FIRST URINE SAMPLE, VOIDS AGAIN ONE HALF LATER AND TESTS THE SECOND SAMPLE
(+) FATTY ACIDS INDICATES INCOMPLETE OXIDATION OF FATS (KETONURIA) ----REQUIRES IMMEDIATE ADJUSTMENT OF DIET AND INSULIN
COMPLICATIONS
HYPOGLYCEMIA OR INSULIN SHOCK
A SYMPTOM OF ABNORMALITIES IN CARBOHYDRATE METABOLISM.
<70 MG/100 ML-MILD, <50 MG- STUPOR
INCREASE IN GLUCOSE DUE TO DELAY IN EATING, OMISSION OF FOOD OR LOSS OF FOOD BY VOMITING AND DIARRHEA, AND DUE TO AN INCREASE IN EXERCISE WITHOUT MODIFICATION OF
INSULIN DOSAGE
PROFUSE SWEATING, MOIST SKIN, PALLOR ; UNEASINESS, FAINTNESS, NERVOUS, WEAK AND HUNGRY, STUPOR AND DEATH IF UNTREATED.
TREATMENT
IMMEDIATE TREATMENT OF CARBOHYDRATE IS ESSENTIAL. <70 MG/DL ---15 G CARBOHYDRATE IS GIVEN E.G., SWEETENED FRUIT JUICES, SODA, SUGAR, CANDY, SYRUP
<50 MG/DL--- IV GLUCOSE IS NECESSARY
HYPERGLYCEMIA/DIABETIC KETOACIDOSIS
13/10/2019
OCCURS WHEN A PERSON HAS INADEQUATE INSULIN DUE TO OMISSION OF INSULIN OR CONSUMPTION OF MORE FOOD THAN THE INSULIN PRESCRIBED.
BODY DEPENDS ON FAT FOR ENERGY AND KETONES ARE FORMED.
IF NOT HANDLED PROPERLY, FLU, COLDS, VOMITING AND DIARRHEA WILL OCCUR. IF UNTREATED IT CAN CAUSE COMA AND DEATH
FEELING OF WEAKNESS, HEADACHE, VOMITING, NAUSEA, ABDOMINAL PAIN, ACHES; SKIN IS HOT, FLUSHED AND DRY
TREATMENT
SMALL REPEATED DOSES OF INSULIN WITH SMALL CARBOHYDRATE FEEDINGS,
FOR DIABETIC COMA- LARGE DOSES OF REGULAR INSULIN WITH SMALL DOSES REPEATED AS NEEDED EVERY HOUR OR UNTIL THE SUGAR IN THE URINE IS REDUCED AND BLOOD SUGAR IS
<200 MG/DL
DEHYDRATION-SALINE SOLUTION
GASTRIC LAVAGE FOR VOMITING
SEVER ACIDOSIS- ALKALI THERAPY
FRUIT JUICES, GRUELS, GINGER ALE, TEA AND BROTH AS SOON AS FLUIDS CAN BE TAKEN
SOFT DIET THAT CONTAINS 100-200 G CARBOHYDRATES ON 2ND DAY
DIET FOR HIS PARTICULAR REQUIREMENTS ON 3RD DAY
LONG-TERM COMPLICATIONS OF DIABETES
DIABETIC RETINOPATHY
AFFECTS THE BACK OF THE EYES WHERE VISUAL IMAGES ARE CONVEYED TO THE BRAIN.
VERY TINY, FRAGILE BLOOD VESSELS PROLIFERATE.
EARLY STAGE, VISION GETS BLURRY, BUT IF BLOOD VESSELS BREAK AND FILL THE EYES WITH BLOOD IT COULD CAUSE BLINDNESS.
CAN BE DETECTED BY DILATED EYE EXAMINATION
BLOOD GLUCOSE CONTROL, BP MONITORING AND REGULAR LIPID TESTS TO PREVENT THIS.
DIABETIC CATARACT
AN OPACITY OF THE LENS THAT OCCURS WHEN DIABETES HAS NOT BEEN CONTROLLED
OCCURS COMMONLY IN ELDERLY DIABETICS
13/10/2019
DIABETIC NEUROPATHY
OCCUR IN ANY PART OF THE BODY, BUT ESPECIALLY IN THE PERIPHERAL NERVES AS IN FEET AND LEGS.
LESIONS OF THE NERVES CAUSE BURNING AND TINGLING SENSATIONS AND NUMBNESS OR NO FEELING AT ALL IN SEVERE CASES.
DAILY INSPECTION OF FEET AND PROPER HYGIENE AND CARE SHOULD BE PRACTICED.
WEAR SOCKS OR ENCLOSED SHOES TO AVOID HARM TO THE FEET.
MINOR WOUNDS COULD CAUSE INFECTION AND COULD LEAD TO AMPUTATION.
DIABETIC GASTROPARESIS
PARTIAL PARALYSIS OF THE NERVES LEADING TO THE MUSCLES OF THE STOMACH.
CHRONIC NAUSEA, VOMITING (ESPECIALLY OF UNDIGESTED FOOD), ABDOMINAL PAIN (A FEELING OF FULLNESS AFTER EATING JUST A FEW BITES
DIETARY CHANGES (LOW-FIBER AND LOW-RESIDUE DIETS AND, IN SOME CASES, RESTRICTIONS ON FAT AND/OR SOLIDS)
DIABETIC NEPHROPATHY
IS A PROGRESSIVE KIDNEY DISEASE CAUSED BY ANGIOPATHY OF CAPILLARIES IN THE KIDNEY GLOMERULI. IT IS CHARACTERIZED BY NEPHROTIC SYNDROME AND DIFFUSE
GLOMERULOSCLEROSIS. IT IS DUE TO LONGSTANDING DIABETES MELLITUS, AND IS A PRIME INDICATION FOR DIALYSIS IN MANY
WESTERN COUNTRIES.
MOST COMMON IS THE CHRONIC KIDNEY DISEASE WHICH IS DEFINED AS A GLOMERULAR FILTRATE RATE OF LESS THAN 60 ML/MINUTE
STAGES
1- HAS GFR OF 90 WITH MINOR OR EARLY KIDNEY DAMAGE.
2-WHEN THE GFR IS BETWEEN 60-89 WHEN THE KIDNEY DAMAGE IS MILD.
3-GFR IS 30-59 AND MODERATE KIDNEY DAMAGE.
4-GFR IS BETWEEN 15-29, SEVERE KIDNEY DAMAGE
5-KIDNEY FAILURE, NEEDS DIALYSIS
5 STAGES OF DIABETIC RENAL INVOLVEMENT
1 GLOMERULAR HYPERFUNCTION AND HYPERTROPHY
2 SILENT STAGE WITH NORMAL URINARY ALBUMIN EXCRETION
3
EARLY DIABETIC NEPHROPATHY
13/10/2019
4 OVERT DIABETIC NEPHROPATHY
5 END-STAGE RENAL FAILURE
EDEMA, FOAMY APPEARANCE OR EXCESSIVE FROTHING OF THE URINE (CAUSED BY THE PROTEINURIA) ,UNINTENTIONAL WEIGHT GAIN (FROM FLUID ACCUMULATION), ANOREXIA (POOR
APPETITE), NAUSEA AND VOMITING, MALAISE (GENERAL ILL FEELING), FATIGUE, HEADACHE AND FREQUENT HICCUPS
MICROALBUMINURIA IS THE INCREASED BUT LOW URINARY EXCRETION INDICATING EARLY CHANGES IN GLOMERULAR PERMEABILITY
INCREASING LEVELS OF ALBUMIN IN URINE INDICATES A PROGRESSIVE DECLINE OF GLOMERULAR FUNCTION
ANNUAL MEASUREMENT OF URINARY ALBUMIN EXCRETION IS USEFUL TO DETECT THE EARLY STAGE OF THE DISEASE.
CARDIOVASCULAR DISORDERS
HEART ATTACKS, ORTHOSTATIC HYPERTESION, AND ERECTILE DYSFUNCTION ARE SOME COMPLICATIONS WHEN DM IS NOT TREATED PROPERLY.
PERIDONTAL DISEASE
INFLAMMATION OF THE GUMS WHEN DENTAL PLAQUE BUILDS UP.
OCCURS BECAUSE SALIVA PRODUCTION DIMINISHES WITH AGING ESPECIALLY WHEN WATER DRINKING IS INADEQUATE
DIABETIC SKIN LESIONS
ANY DAMAGE TO THE SKIN OF THE DIABETIC PATIENT WILL EITHER HEAL SLOWLY OR WILL NEVER HEAL AT ALL.
A GANGRENOUS CONDITION MIGHT OCCUR
ATHEROSCLEROSIS AND POOR CIRCULATION OF THE BLOOD ARE CAUSATIVE FACTORS FOR DELAYED HEALING.
DIABETIC FOOT
A MANIFESTATION OF CHRONIC NEUROPATHY AGGRAVATED BY VASCULAR INSUFFICIENCY AND INFECTION.
SENSORY LOSS ALLOWS TOLERANCE OF REPEATED TRAUMA FROM TIGHT SHOES AND IMPROPER WEIGHT BEARING, WHICH LEADS TO SKIN BREAKDOWN, SKIN ULCERATION, TISSUE NECROSIS
AND FRACTURE.
MANAGEMENT AND TREATMENT
PROPHYLACTIC FOOT CARE INCLUDES PROPERLY FITTING SHOES, DAILY EXAMINATION
PT WITH FOOT ULCERS MUST AVOID LOCAL PRESSURE TO ALLOW HEALING
DEBRIDEMENT AND BROAD-SPECTRUM ANTIBIOTICS ARE USED
FOR INJURY, AND CARE IN THE MANAGEMENT OF CALLUSES AND IN NAIL CUTTING AND CLEANING.
13/10/2019
AMPUTATION MAY BE NECESSARY
TO PREVENT RECURRENT SEPTICEMIA AND DEATH
MANAGEMENT OF DIABETES
TO DATE, THERE IS NO CURE FOR DIABETES; THE PATIENT MUST LEARN TO LIVE WITH THE DISEASE. GLYCEMIC CONTROL IS FUNDAMENTAL TO THE MANAGEMENT
CONTROL OF BLOOD PRESSURE AND LIPIDS TO HELP PROMOTE A PROLONGED HEALTHY AND SATISFYING LIFE.
OF DIABETES, SO IS THE
BASIC CONTROL OF DIABETES:
1. INSULIN OR ORAL HYPOGLYCAEMIC AGENTS
2. HEALTHY EATING
3. REGULAR EXERCISES SUITABLE FOR ONE’S MEDICAL CONDITION.
4. AVOID STRESS FACTORS: THE CONTROLLABLE AND THE UNCONTROLLABLE FACTORS.
DIABETES SELF-MANAGEMENT EDUCATION (DSME)
– IT IS THE ONGOING PROCESS OF FACILITATING THE KNOWLEDGE, SKILL, AND ABILITY NECESSARY FOR DIABETES SELF-CARE.
CONTENT AREAS FOR DSME ARE THE FOLLOWING:
* DESCRIBING THE DIABETES DISEASE PROCESS AND TREATMENT OPTIONS.
* INCORPORATING NUTRITIONAL MANAGEMENT INTO LIFESTYLE.
* INCORPORATING PHYSICAL ACTIVITY INTO LIFESTYLE.
* USING MEDICATION(S) SAFELY FOR MAXIMUM THERAPEUTIC EFFECTS.
* MONITORING BLOOD GLUCOSE AND OTHER PARAMETERS AND INTERPRETING AND USING THE RESULTS FOR SELF-MANAGEMENT DECISION MAKING.
*PREVENTING, DETECTING, AND TREATING ACUTE AND CHRONIC COMPLICATIONS.
* DEVELOPING PERSONAL STRATEGIES TO ADDRESS SOCIAL ISSUES AND CONCERNS AND TO PROMOTE HEALTH AND BEHAVIOUR CHANGE.
THE OVERALL OBJECTIVES OF DSME ARE TO SUPPORT INFORMED DECISION-MAKING, SELF CARE BEHAVIOURS, PROBLEM-SOLVING AND ACTIVE COLLABORATION
CARE TEAM AND TO IMPROVE CLINICAL OUTCOMES, HEALTH STATUS AND QUALITY OF LIFE.
WITH THE HEALTH
13/10/2019
,
.
INSULIN
MOST PEOPLE WITH TYPE 1 DIABETES START OFF WITH AT LEAST TWO INJECTIONS A DAY AND MAY HAVE AS MANY AS FOUR OR MORE, DEPENDING ON YOUR DOCTOR’S ASSESSMENT OF
YOUR NEED. AS INCONVENIENT AS MULTIPLE INJECTIONS EACH DAY MAY SOUND, RESEARCH HAS SHOWN THAT MORE DAILY INSULIN DOSES PROVIDE BETTER CONTROL OF BLOOD GLUCOSE.
AND BETTER GLUCOSE CONTROL MEANS REDUCING THE RISK OF SHORT AND LONG-TERM HEALTH COMPLICATIONS.
INSULIN, ORAL HYPOGLYCEMIC AGENTS AND INJECTABLES
PHYSIOLOGIC INSULIN HAS IMMEDIATE ONSET; IT PEAKS IN ½-1 HOUR AND LAST 2-3 HOURS. THE DIABETIC PATIENT SECRETES EITHER INSUFFICIENT INSULIN OR NONE. WHEN THE BODY
DOES NOT MANUFACTURE ENOUGH INSULIN, THE PATIENT MUST RESORT ON COMMERCIAL INSULIN PREPARATIONS. ALL INSULIN PREPARATION AVAILABLE IN THE PHILIPPINES ARE MADE
FROM RECOMBINANT DNA TECHNOLOGY.
DIFFERENT KINDS OF INSULIN
1
RAPID-ACTING
STARTS TO WORK IN ABOUT 5 MINUTES, REACHES THE PEAK OF EFFECTIVENESS IN ABOUT ONE HOUR AND CONTINUES WORKING FOR UP TO FOUR HOURS.
2
REGULAR OR SHORT-ACTING
THIS TYPE OF INSULIN BEGINS TO WORK IN ABOUT 30 MINUTES, REACHES THE PEAK OF EFFECTIVENESS ANYWHERE BETWEEN TWO AND THREE HOURS AND CONTINUES WORKING UP TO SIX
HOURS.
3
INTERMEDIATE-ACTING
USUALLY BEGINS TO WORK IN TWO TO FOUR HOURS, REACHES THE PEAK OF EFFECTIVENESS ANYWHERE BETWEEN TWO AND THREE HOURS AND CONTINUES WORKING UP TO SIX HOURS.
4
LONG-ACTING
USUALLY BEGINS TO WORK IN SIX TO TEN HOURS AND CONTINUES WORKING UP TO 24 HOURS.
METHODS OF INSULIN THERAPY
INSULIN PEN
INSULIN INJECTIONS
EXTERNAL INSULIN PUMP
IMPLANTABLE INSULIN PUMP
1.) INSULIN PEN
LOOKS LIKE A PEN.
13/10/2019
USERS MUST NEED TO SELECT THE CORRECT DOSE OF INSULIN USING A DIAL.
A PLUNGER IS PRESSED IN ORDER TO DELIVER INSULIN TO THE USER.
2.) INSULIN INJECTIONS
DELIVERS INSULIN THROUGH THE SKIN.
3.) EXTERNAL INSULIN PUMP
A NEEDLE CONNECTED TO A PLASTIC TUBING THAT IS INSERTED JUST UNDER THE SKIN NEAR THE ABDOMEN.
THE PATIENT MUST PROGRAM THE INSULIN PUMP ACCORDING TO HIS/HER NEEDS
4.) IMPLANTABLE INSULIN PUMP
SMALL DISC SHAPED PUMPS.
SURGICALLY IMPLANTED. USUALLY ON THE LEFT SIDE OF THE ABDOMEN.
DELIVER SMALL AMOUNT OF INSULIN THROUGHOUT THE DAY.
REMOTE CONTROLLED.
DIETARY MANAGEMENT OF DIABETES MELLITUS
PROPER DIETARY MANAGEMENT STILL REMAINS THE MOST IMPORTANT FACTOR IN THE TREATMENT OF DIABETES MELLITUS.
DIET SHOULD BE INDIVIDUALIZED TO MEET THE PATIENT’S SPECIFIC NEEDS, AND TO BE EFFECTIVE, HE/SHE MUST BE AWARE OF THE RATIONALE FOR THE DIETARY RESTRICTIONS.
ACHIEVING A BALANCE BETWEEN FOOD INTAKE, MEDICATION (ESPECIALLY INSULIN LEVELS) AND ENERGY EXPENDITURE IS AN ESSENTIAL PREREQUISITE FOR ACHIEVING GLYCEMIC CONTROL.
THE MAKING OUT OF THE DIET PRESCRIPTION SHOULD BE DETERMINED BY THE PHYSICIAN. PATIENT INTERVIEW, USUALLY CONDUCTED BY THE DIETITIAN, SHOULD INCLUDE A CAREFULLY
RECORDED DIET HISTORY. THIS INCLUDES:
* SOCIO-ECONOMIC CONDITIONS
* FOOD ATTITUDES
* EATING HABITS
ENERGY ALLOWANCE
ENERGY ALLOWANCE IS DETERMINED BASED ON THE PATIENT’S HEIGHT, WEIGHT, BMI, AGE, SEX, AND ACTIVITY.
13/10/2019
ATTAINING THE DESIRABLE BODY WEIGHT OF THE PATIENT SHOULD BE THE PRIMARY OBJECTIVE OF THESE DIET SO AS THE ACTUAL WEIGHT OF THE PATIENT SHOULD BE THE OBJECT OF
CAREFUL ANALYSIS AND CONTROL OF TOTAL ENERGY INTAKE.
THE FOLLOWING IS AN ACTIVITY GUIDE FOR CALCULATING THE TOTAL ENERGY REQUIREMENT:
PEOPLE WITH T YPE 2 DIABETES TEND TO BE OVERWEIGHT. IN THIS CASE, NUTRITIONALLY ADEQUATE CALORIC RESTRICTIONS AND MODERATE WEIGHT LOSS ( 10 – 20 LBS ) HAVE BEEN
SHOWN TO IMPROVE DIABETES CONTROL, EVEN IF THE DESIRABLE BODY WEIGHT IS NOT ACHIEVED. WEIGHT REDUCTION SHOULD BE INITIATED SOON AFTER T YPE 2 DM IS DIAGNOSED,
WHEN INSULIN SECRETION IS STILL ADEQUATE. E XERCISE, BEHAVIOR MODIFICATION OF EATING HABITS, AND PSYCHOLOGICAL SUPPORT ARE ADDITIONAL STRATEGIES TO IMPROVE
COMPLIANCE WITH CALORIC PRESCRIPTION. ( JAMORABO-RUIZ, CLAUDIO AND DIAMONON. “NUTRITION AND DIET THERAPY FOR NURSING” (2011) PP 388-389. )
CARBOHYDRATE ALLOWANCE
IN DIABETIC PATIENTS, THE RANGE OF CARBOHYDRATE INTAKE SHOULD BE 45–65%, INSTEAD OF THE NORMAL 50 – 70%.
FOODS CONTAINING CHO FROM WHOLE GRAINS, FRUITS, VEGETABLES AND NON-FAT DAIRY PRODUCTS ARE EMPHASIZED.
PATIENTS SHOULD BE ADVISED TO BE CAREFUL IN THEIR CONSUMPTION OF SUCROSE-CONTAINING FOODS. FRUCTOSE, IF TAKEN IN LARGE AMOUNTS, HAS POTENTIAL ADVERSE EFFECTS ON
SERUM CHOLESTEROL AND LOW DENSITY LIPOPROTEIN CHOLESTEROL.
GLYCEMIC INDEX (GI)
IS THE CHANGE IN THE BLOOD GLUCOSE AFTER INGESTION OF A PARTICULAR FOOD IN COMPARISON WITH THE CHANGE IN BLOOD GLUCOSE AFTER EATING A STANDARD FOOD.
USED TO QUANTIFY AND COMPARE THE 2-HOUR GLYCEMIC RESPONSE OF INDIVIDUALIZED FOODS.
THE RESPONSE IS INFLUENCED BY THE SOURCE AND THE FORM OF CARBOHYDRATES AND BY THE PRESENCE OF FIBER, AND THE LENGTH OF TIME REQUIRED FOR DIGESTION AND
METABOLISM.
* FOODS WITH LOW GLYCEMIC INDEX HAVE BEEN PROPOSED TO HAVE POTENTIAL BENEFICIAL EFFECT IN THE MANAGEMENT
OF
DM.
GLYCEMIC LOAD (GL)
COMBINATION OF THE GI AND THE TOTAL CARBOHYDRATE CONTENT OF AN AVERAGE
SERVING OF A FOOD.
DEFINED AS:
WEIGHTED MEAN OF THE DIETARY
GI X (% TOTAL ENERGY FROM CHO
*DIETS HIGH IN CARBOHYDRATES(HIGH IN GL) WITH LOW GLYCEMIC INDEX ARE BEST FOR CARDIOVASCULAR RISK REDUCTION.
*THE BRAIN AND CNS HAVE AN ABSOLUTE REQUIREMENT FOR GLUCOSE, THUS INTAKES OF <130G/DAY ARE NOT RECOMMENDED.
PROTEIN ALLOWANCE
THE PROTEIN FOR THE DIABETIC PATIENT IS THE SAME AS THAT OF THE NORMAL INDIVIDUAL.
13/10/2019
INTAKE OF PROTEIN ABOVE 20% MAY BE A RISK FACTOR IN DEVELOPING DIABETIC NEPHROPATHY.
RESTRICTED PROTEIN DIETS MAY MODIFY THE UNDERLYING GLOMERULAR INJURY WHILE CONTROLLING HYPERTENSION AND HYPERGLYCEMIA, DELAY THE PROGRESSION OF RENAL FAILURE.
FAT ALLOWANCE
RECOMMENDATION IS USUALLY 25-30%, HOWEVER HIGHER AMOUNT CAN BE GIVEN BUT SHOULD NOT EXCEED 35%.
*DIABETICS ARE SUSCEPTIBLE TO ATHEROSCLEROSIS AND ITS COMPLICATION; THUS, CONSUMPTION OF SATURATED FATS IS LIMITED TO 1/3 OR LESS FAT CALORIES AND UNSATURATED FAT
MUST PROVIDE 2/3 OF THE FAT CALORIES(1/3 MONOUNSATURATED, 1/3 POLYUNSATURATED)
DIABETES MEAL PLAN
A MEAL PLAN FOR PATIENTS DIAGNOSED WITH DIABETES MELLITUS.
PEOPLE WITH DIABETES HAVE TO TAKE EXTRA CARE TO MAKE SURE THAT THEIR FOOD IS BALANCED WITH INSULIN AND ORAL MEDICATIONS, AND EXERCISE
GLUCOSE LEVELS.
TO HELP MANAGE THEIR BLOOD
*THE SIMPLEST IS THE PLATE METHOD WHERE THE PLATE IS DIVIDED INTO IMAGINARY QUARTERS: ¼ STARCHES(RICE, BREAD OR PASTA), ¼ FOR MEAT, FISH, POULTRY AND ½ FOR
VEGETABLES.
SAMPLE MEAL PLAN
SAMPLE PATIENT: A 5’2” ADULT DIABETIC WOMAN WHO IS UNDERWEIGHT AND ENGAGED IN SEDENTARY ACTIVITIES.
HT IN CM
= 5(12)(2.54)= 152.4
(2)(2.54)=
5.08
157.48 CM
DBW= 157.48CM – 100 (-10%)
= 57.48 – 5.748
TER = 51.73 X 30
MACRONUTRIENTS:
CARBOHYDRATES = 1551.9KCAL (0.6)
4KCAL/G
13/10/2019
PROTEIN
= 1551.9KCAL (0.15)
4KCAL/G
FAT
=1551.9KCAL (0.25)
9KCAL/G
DIET RX: 1551.9KCAL, CHO 232.78G, CHON 58.20G, FAT 43.12G
SAMPLE MENU:
BREAKFAST:FRUIT
: MELON – 1 EXCHANGE(1 SLICE)
PROTEIN DISH : HARD BOILED EGG – 1 EXCHANGE(1 PIECE)
BREAD
: SLICE BREAD – 2 EXCHANGES(4 SLICES)
BUTTER
: BUTTER – 2 ½ EXCHANGES(2 ½ TEASPOONS)
MILK
: EVAP. UNDILUTED – 1 EXCHANGE(½ CUP)
LUNCH:
FRUIT
: BANANA – 1EXCHANGE(1 SMALL)
PROTEIN DISH
: BANGUS(SINIGANG) –1½ EXCHANGES(1½ MBS)
VEGETABLE
: KANGKONG – (-)(¼ CUP)
RADISH – (-)(¼ CUP)
SITAO – 1 EXCHANGE(½ CUP)
RICE
: BOILED RICE – 3 EXCHANGES(1½ CUPS)
DINNER:
FRUIT
: BANANA – 1EXCHANGE(1 SMALL)
PROTEIN DISH
: CHICKEN ADOBO – 1½ EXCHANGES(1 MED LEG)
VEG. DISH
: SQUASH GUISADO – 1 EXCHANGE(½ CUP)
RICE
: BOILED RICE – 3 EXCHANGES(1½ CUPS)
* COOKING FATS USED – 2½ EXCHANGES(2½ TEASPOONS)
13/10/2019
ARTIFICIAL SWEETENERS
THESE CAN BE USED BY PEOPLE WITH DIABETES AND MAY HELP TO CONTROL CALORIC INTAKE AS THESE SWEETENERS DO NOT AFFECT BLOOD SUGAR LEVEL. ANY SWEETENER SHOULD BE
USED IN MODERATION.
SWEETENING AGENTS:
1. SACCHARIN
IS A WIDELY USED SWEETENING AGENT. IT MAY BE ADDED TO BEVERAGES
MG/DAY FOR ADULTS AND 500 MG/DAY FOR CHILDREN.
AND FOODS THAT DO NOT REQUIRE COOKING.
THE ACCEPTABLE DAILY INTAKE FOR SACCHARIN IS 1000
2. ACESULFAME-K
IS A NON-NUTRITIVE SWEETENER 200 TIMES SWEETER THAN SUCROSE AND SUITED FOR BAKING.
3. ASPARTAME
IS AN ARTIFICIAL SWEETENER WIDELY USED IN A VARIETY OF PRODUCTS AND HAS NO ADVERSE EFFECTS FOUND. US ADI IS 50 MG/KG/DAY.
4. SUCRALOSE
A NON-CALORIC HIGH INTENSITY SWEETENER DERIVED FROM ORDINARY SUGAR.
5. NEOTAME
THE NEWEST NON-NUTRITIVE SWEETENER APPROVED BY THE USFDA IN 2002. ITS SAFE EXPECTED DAILY INTAKE IS 0.1 MG/KG BODY WEIGHT.
6. ALITAME
ANOTHER NUTRITIVE SWEETENER EXPECTED TO GET APPROVED FROM THE USFDA. IT CONTAINS 1.4 KCAL /G AND IS HIGHLY STABLE AND CAN WITHSTAND TEMPERATURE IN
COOKING AND BAKING.
5. CYCLAMATES
30 TIMES AS SWEET AS CANE SUGAR, WERE USED TO SWEETEN SOFTDRINKS IN BRITAIN IN 1964 AND 1967, HOWEVER IN 1969, IMMEDIATELY STOPPED FOLLOWING A TOXICITY
REPORT ON RAT.
6. CALORIC OR NUTRITIVE SWEETENERS
INCLUDE SUCROSE, FRUCTOSE AND SORBITOL AND OTHER SUGAR ALCOHOLS
7. FRUCTOSE
1.0 TO 1.8 TIMES SWEETER THAN SUCROSE AND IT IS MOST SWEET IN A SLIGHTLY COLDER, SLIGHTLY ACIDIC FOOD. MAXIMUM ACCEPTED INTAKE IS 75G, OFTEN USED IN “DIABETIC”
.
13/10/2019
1.0
1.8
,
COMMERCIAL PRODUCTS.
.M
75 ,
“
”
8. SORBITOL, MANNITOL AND XYLITOL
SUGAR ALCOHOL DERIVATIVES ALSO ADDED TO DIABETIC FOODS AND DRINKS FOR SWEETENING PURPOSES.
ADVANTAGEOUS FOR DIABETICS.
SORBITOL-2.6KCAL/G; MANNITOL-1.6KCAL/G; XYLITOL-2.4KCAL/G
ABSORBED FAR SLOWER INTO THE BLOODSTREAM AND CONSIDERED
9. STEVIA
LATEST SUGAR SUBSTITUTE THAT IS CLOSEST TO TABLE SUGAR, BUT MOST EXPENSIVE.
EXTRACTS.
MANUFACTURED FROM STEVIA LEAVES. AVAILABLE AS TABLETS, LIQUIDS, POWDERS AND
10. FIBER
CURRENT EVIDENCES SUGGESTS THAT HIGH-FIBER DIETS MAY OFFER SOME IMPROVEMENT IN CARBOHYDRATE METABOLISM, MAY LOWER CHOLESTEROL AND LOW DENSITY
LIPOPROTEIN CHOLESTEROL AND INCREASE THE SATIETY EFFECT OF A MEAL.
11. ALCOHOL
MAY CAUSE SPECIFIC PROBLEMS WITH HYPOGLYCEMIA, NEUROPATHY, GLYCEMIC CONTROL, OBESITY, HYPERLIPIDEMIA.
HYPOCALORIC DIET.
CONTAINS 7 KCAL/G, CONTRAINDICATED IN INDIVIDUALS ON A
GUIDELINES
ALCOHOL SHOULD BE CONSUMED IN MODERATION, NOT MORE THAN 2 EQUIVALENTS OF ALCOHOL ONCE OR TWICE PER WEEK.
INDIVIDUALS TAKING HYPOGLYCEMIC MEDS SHOULD NOT DRINK ALCOHOL.
ALCOHOL SHOULD ONLY BE INGESTED WITH MEALS TO AVOID POTENTIAL HYPOGLYCEMIC EFFECT.
ALCOHOL AND ITS EQUIVALENT CALORIC CONTENT SHOULD BE CALCULATED INTO THE MEAL PLAN. ONE EQUIVALENT IS EQUAL TO 90 KCAL (2 FAT EXCHANGES)
EXERCISE
EXERCISE (DIABETES)
HELP REGULATE DIABETES
BY PROMOTING GLUCOSE UTILIZATION AND IMPROVING BLOOD CIRCULATION
PROMOTE WEIGHT LOSS
IMPROVE INSULIN SENSITIVITY
GLUCOSE TOLERANCE IN INDIVIDUALS WITH BOTH TYPES OF DIABETES MELLITUS
13/10/2019
IMPROVE GLYCEMIC CONTROL
RISK OF EXERCISE
FOR INDIVIDUALS WITH
DIABETES
TYPE I DIABETIC PATIENT
UNDERINSULINIZED PATIENTS OR IN POORLY CONTROLLED DIABETES WITH PRE-EXERCISE BLOOD GLUCOSE LEVELS OF 250-300 MG/DL
INCREASED HYPERGLYCEMIA MAY PREVAIL.
― INSUFFICIENT INSULIN  GLUCOSE USED BY MUSCLES IS DECREASED  LIVER RELEASE STORED GLUCOSE TO MAKE FOR THE MUSCLE DEFICIT  INCREASED BLOOD GLUCOSE
ARRHYTHMIA OR MYOCARDIAL INFARCTION
WORSENING MICROVASCULAR DIABETIC COMPLICATIONS WITH OTHER ARTHEROSCLEROTIC CARDIOVASCULAR DISEASE
EXERCISE FOR THOSE WHO HAVE DIABETES
PARTICIPATE IN EITHER RECREATIONAL OR COMPETITIVE PHYSICAL ACTIVITIES
― TO IMPROVE CARDIOVASCULAR FITNESS AND PSYCHOLOGICAL WELL-BEING AND;
― FOR SOCIAL INTERACTION AND RECREATION
BEFORE UNDERTAKING EXERCISE:
INDIVIDUAL SHOULD RECEIVE A COMPLETE MEDICAL EVALUATION
SHOULD BE TAILORED TO THE INDIVIDUAL’S CAPABILITIES, PREFERENCES, AGE, LIFESTYLE
AEROBIC EXERCISE IS RECOMMENDED FOR CARDIOVASCULAR FITNESS
TYPE I DIABETIC
― SELF MONITORING BLOOD GLUCOSE (SMBG) IS IMPORTANT IN DECIDING WHEN TO EXERCISE
― SHOULD ALWAYS CARRY DIABETIC IDENTIFICATION CARD OR A BRACELET
― SHOULD KNOW THE SOURCES OF EASILY AVAILABLE CARBOHYDRATE
― MUSCLES CAN BE SENSITIVE TO INSULIN FOR UP TO 24 HOURS AFTER EXERCISE
― REPLACEMENT OF LIVER AND MUSCLE GLYCOGEN STORES
TYPE I DIABETIC PATIENT WHO EXERCISE AT ABOUT TIME DAILY
AND HOW TO TREAT POTENTIAL HYPOGLYCEMIA
13/10/2019
― SHOULD HAVE A MEAL PLAN THAT PROVIDES ENOUGH KCAL TO COVER THE EXERCISE
TYPE I DIABETIC PATIENT WHO EXERCISE SPORADICALLY OR LESS THAN DAILY
― MAY CHOOSE TO LOWER THE INSULIN DOSE AND/OR INCREASE FOOD INTAKE TO REGULATE BLOOD GLUCOSE LEVELS AFTER CONSULTATION
TYPE 2 DIABETIC PATIENT
―GLYCEMIC CONTROL CAN IMPROVE WITH EXERCISE DUE TO INCREASED INSULIN SENSITIVITY
― WALKING 2,500 STEPS OR MORE PER DAY CAN BE HELPFUL IN LOSING WEIGHT AND HAVE A GREATER DROP IN BLOOD PRESSURE (HEALTH MAGAZINE)
POSTPRANDIAL HYPERGLYCEMIA
― EXERCISE AFTER EATING WILL BE BENEFICIAL
DIETARY GUIDELINES FOR GESTATIONAL DIABETES
BE FAMILIAR WITH CLIENT’S HEIGHT AND WEIGHT, HISTORY OF PREVIOUS PREGNANCIES, BLOOD PRESSURE READINGS, AND RECORDS OF BLOOD GLUCOSE.
EMPHASIZE 3 SMALL MEALS AND BETWEEN-MEAL SNACKS
FRUITS SHOULD BE PLANNED AS MID-MORNING SNACK BECAUSE THE FASTING BLOOD SUGAR OF WOMEN IS USUALLY HIGH IN THE MORNING DUE TO HORMONAL RELEASE.
DIETARY GUIDELINES FOR GESTATIONAL DIABETES
CHOOSE STARCHY FOODS LIKE WHOLE GRAINS AND HIGH IN DIETARY FIBER TO PREVENT CONSTIPATION.
3 SERVINGS OF FRUIT FOR LUNCH, MID-AFTERNOON SNACK, AND DINNER.
5-6 SERVINGS OF NONSTARCHY DARK-COLORED VEGETABLES (BROCCOLI, RED LETTUCE, EGGPLANT, TOMATOES)
2-3 GLASSES OF LOW-FAT MILK OR EQUIVALENT AND THE RIGHT KIND OF FATS AND OILS.
KEEP SATURATED FATS UNDER 10% OF TOTAL FAT.
DIETARY GUIDELINES FOR GESTATIONAL DIABETES
40-45% CHO, 30-35% CHON, 30-35% F
SUPPLEMENTS PRESCRIBED CONTAIN 600 MCG FOLIC ACID, ADEQUATE VITAMIN C, AND OTHER B- VITAMINS.
SUPPLY IRON NO LESS THAN 30 MG/DAY.
CAUTION ON SODIUM INTAKE WHEN THERE IS PRE-ECLAMPSIA OR RISKS OF HYPERTENSION.
MANAGEMENT OF DIABETES IN CHILDREN
13/10/2019
ONSET OF SYMPTOMS IS USUALLY MORE SUDDEN AND SEVERE, AND TENDS TO INCREASE IN SEVERITY DURING THE PERIOD OF GROWTH.
OBESITY, IN CONTRAST TO ADULTS IS UNCOMMON; IN FACT, MOST DIABETIC CHILDREN ARE UNDERWEIGHT.
ALL DIABETIC CHILDREN NEED INSULIN.
ADDITIONAL NUTRIENTS NEEDED FOR GROWTH AND THE VARYING ACTIVITY FROM TIME TO TIME REQUIRES FREQUENT DIETARY ADJUSTMENTS.
MANAGEMENT OF DIABETES IN CHILDREN
INSULIN TREATMENT
REQUIREMENTS FOR INSULIN ARE OFTEN VARIABLE DUE TO FLUCTUATING ACTIVITIES (SEDENTARY TO VERY ACTIVE).
EXECCIVE ACTIVITY = HYPOGLYCEMIA
LETHARGY (EG. FROM INFECTIOUS DISEASES) = HYPERGLYCEMIA
SUITABLE COMBINATION: DEPOT INSULIN (INSULIN FORMED IN THE SUBCUTANEOUS TISSUE; LONG-ACTING) + 1 DOSE OF SOLUBLE INSULIN BEFORE BREAKFAST + 1 DOSE OF SOLUBLE
INSULIN BEFORE SUPPER
MANAGEMENT OF DIABETES IN CHILDREN
DIET THERAPY
DIETARY MODIFICATIONS SAME AS FOR ADULTS.
NUTRITIVE REQUIREMENTS SAME AS NORMAL CHILD OF SAME AGE, SIZE AND ACTIVITY.
GOAL: MAINTENANCE OF NORMAL GROWTH AND DEVELOPMENT.
MANAGEMENT OF DIABETES IN CHILDREN
MANAGEMENT OF DIABETES IN CHILDREN
MINERALS AND VITAMINS
ADDITIONAL CALCIUM REQUIREMENTS: 3-4 CUPS OF MILK/DAY
GENEROUSLY SUPPLIED WITH LEAFY GREEN AND YELLOW VEGETABLES AS WELL AS APPROPRIATE COOKING OIL AND BUTTER OR MARGARINE (VITAMINS + FAT).
PROBLEMS: FAT AND SODIUM RICH FOODS CONSUMPTION, SKIPPING MEALS, EATING OUT, ALCOHOL CONSUMPTION BY SOME, DISLIKE FOR CERTAIN VEGETABLES AND LACK OF
PROFESSIONAL GUIDANCE.
13/10/2019
6
IT IS REGARDED AS A DISEASE OF MULTIFACTORIAL INHERITANCE. GENETICS AND ENVIRONMENT PLAY A MAJOR ROLE
7
INSULIN
PRODUCED BY THE BETA CELLS OF THE PANCREAS IS INSUFFICIENT AS IN THE CAUSE OF TYPE
8
CLASSIFICATION AND DIAGNOSIS OF DIABETES
9
TYPE 1
2 DM OR IS TOTALLY LACKING BECAUSE THE BETA CELLS ARE DAMAGED AS IN TYPE 1 DM
RESULTS FROM BETA CELL DESTRUCTION
LEADING TO ABSOLUTE INSULIN DEFICIENCY
TYPE
2
RESULTS FROM A PROGRESSIVE INSULIN SECRETORY DEFECT ON THE BACKGROUND OF INSULIN RESISTANCE
10
DUE TO OTHER CAUSES, GENETIC DEFECTS IN BETA CELLS DESTRUCTION, GENETICS IN INSULIN ACTION, DEISES OF THE EXOCRINE PANCREASE, DRUG OR CHEMICALLY INDUCED DM
GESTATIONAL DIABETES
DIAGNOSED DURING PREGNANCY
11
CRITERIA FOR DX OF DM
1. AIC ≥ 6.5%TEST SHOULD BE PERFORMED IN A LABORATORY
USING A METHOD THAT IS CERTIFIED AND STANDARDIZED TO THE
DCCT ASSAY
2. FPG≥126 MG/DL(7.0MMOL/L) FASTING IS DEFINED AS NO CALORIE INTAKE FOR ATLEAST 8 HRS
3. 3.2-H PLASMA GLUCOSE 200 MG/DL(11.1MMOL/L) DURING AN OGTT,
USING A GLOCUSE LOAD CONTAINING THE EQUIVALENT OF 75-G ANHYDROUS GLUCOSE DISSOLVED IN WATER
4. IN A PATIENT WITH CLASSI SYMPTOMS OF HYPERGLYCEMIA OR HYPERGLYCEMIC CRISIS,A RANDOM PLASMA GLOCUSE ≥200 MG/DL(11.1MMOL)
12
RECENT STUDIES SHOWS THAT MODEST WEIGHT LOSS AND REGULAR PHYSICAL ACTIVITY CAN REDUCE THE RATE OF PROGRESSION OG IGT TO TYPE 2 DM. DRUG THERAPY HAS BEEN
SHOWN TO BE EFFECTIVE IN REDUCING PROGRESSION TO DIABETES .THOUGH GENERALLY NOT AS EFFECTIVELY AS INTENSIVE LIFESTYLE INTERVENTIONS.
13
FAMILY HISTORY & PAST DIAGNOSIS
OBESITY
DELIVERED A BABY GREATER THAN
LEAD TO:
DIABETES MELLITUS
9LBS
13/10/2019
D
14
ELEVATED BLOOD SUGAR (HYPERGLYCEMIA)
- NO APPROPRIATE LEVEL OF INSULIN TO HELP GLUCOSE ENTER THE CELLS OR INSULIN ACTION IS NOT RECOGNIZED BY CELL’S RECEPTORS
INCREASED HUNGER (POLYPHAGIA)
-GLUCOSE IS NOT UTILIZED BY THE CELLS, WHICH SIGNAL THE NEED FOR GLUCOSE
FREQUENT URINATION (POLYURIA)
-LOSS OF WATER AND ELECTROLYTE
INCREASED THIRST (POLYDIPSIA)
- TRIGGERS THE NEED FOR REPLACEMENT IF WATER LOST IN THE URINE
SUGAR IN URINE (GLUCOSURIA)
- EXCESS GLUCOSE SPILLS INTO THE URINE (RENAL THRESHOLD – 180 MG/L)
DRAMATIC WEIGHT LOSS AND WEAKNESS
- CELLS DO NOT RECEIVE ENOUGH GLUCOSE FOR ENERGY AND STORAGE
FLUCTUATION IN VISUAL ACTUITY
- DUE TO HYPERGLYCEMIA AFFECTING THE CIRCULATION IN THE EYES
DELAYED WOUND HEALING
- PROTEIN UTILIZATION IS DECREASED
SUSCEPTIBILITY TO INFECTIONS
- IMMUNE SYSTEM IS AFFECTED
15
TYPE 1 DIABETES
Occurs in young,lean patients and is characterized by a marked inability of the patient
Inability of the pancreas to secrete insulin and depend on exogenous source of insulin to sustain their lives.
This results in abnormally high levels of sugar in the blood leading to gradual deterioration of some organs and a decreased life span of around 15 years.
In turn,it produces increasing amount of acidic compounds called ketone bodies.
Former names: insulin dependent diabetes mellitus and juvenile onset diabetes.
16
Signs and sympomts: those in the table plus
13/10/2019
Signs and sympomts: those in the table plus
 very dry skin
Sores thatt are slow to heal
more infections than the usual,
nausea,
vomiting,
and stomach pains
feeling very tires much of the time
17
TYPE 2
Previously called adult onset diabetes or non-insulin dependent DM
Body’s inability to make enough or properly use insulin
Most common from accounting for 90-95% of diabetes
Usually appears after the age of 40,and many type 2 diabetocs are not aware they have the disease until severe complications occur
Increased with age and obesity

18
MAJOR 3 METABOLIC DEFECTS THAT CONTRIBUTE TO HYPERGLYCEMIA TYPE 2
Increased glocuse production in the liver
Impaired insulin secretions by the pancreatic isles cells
insulin resistance in skeletal muscle
19
Dry mouth
Nausea
Occasional vomiting
Blurred vision
Frequent infections of the skin
UTI or vaginal problems with their lipid profile
Serum triglycerides and low density lipoprotein are elevated while high-density lipoprotien is reduced, this is why patients are prone to ischemic vascular disease
20
GESTATIONAL DIABETES MELLITUS
Is a carbohydrate intolerance of variable severity with onset of recognition during the present pregnancy
Typically diagnosed during present pregnancy.3rd trimester and is related to the metabolic changes during pregnancy
It is the effect of insulin resistance. While pregnant woman produces plentiful amounts of insulin, its action is partially blocked by a variety of hormones base in the
placenta such as estrogen, cortisol, and human placental lactogen. This contra-insulin effect takes place to abot 20-24 weeks.The larger the placenta grows the more
hormones are produced, thus the greater the insulin resistance
13/10/2019
hormones are produced, thus the greater the insulin resistance

21
TIME: PLASMA GLUCOSE LEVEL
FASTING: LESS THAN 95MG/DL (5.3 MMOL/L)
1 HOUR: LESS THAN 180 MG/DL (10MMOL/L)
2 HOURS: LESS THAN 155 MG/DL (8.6MMOL/L)
3 HOURS: LESS THAN 140MG/DL(7.8MMOL/L)
22
Pregnant women with a family history of diabetes, having given birth previously to a very large infant, a stillbirth or a child with birth defect, and having too much
amniotic fluid are those who are liable to develop GDM. Gestational diabetes is usually asymptomatic but controlled blood sugar may lead to infant macrosomia and
hypoglycemia (after birth).
23
METABOLISM IN DIABETES MELLITUS
Fat metabolism. Fatty acid synthesis in DM decreases resulting in lipogenesis (fat formation) while fatty oxidation increase lipolysis (fat breakdown). Glycogen stores of
the liver are depleted with the failure to synthesize glycogen and to utilize glucose. In such circumstance, the metabolic needs are met by breaking down of large
quantities of fatty acids. The fatty acid release from the adipose tissue and available by absorption in the intestinal tract are oxidized by the liver resulting in the
formation of ‘’ketone bodies’’ such as acetoacetic acid, beta-hydroxybutyric acid and acetone, which accumulate in the blood, a condition called ketosis. The acid base
equilibrium is disturbed; its depletion leads ultimately to acidosis.
24
Role of insulin – Normally insulin signals the body that it has been fed and directs cellular activities that favor the storage of protein, carbohydrateand fat.
Specifically,insulin stimulates glucose utilization in the skeletal muscles,heart and some other tissues.It also increase skeletal muscle blood flow which depends on
release of nitric oxide by the endothelium of the muscular vessels;increasing blood flow in the muscles increase glucose utilization.

25
Carbohydrate Metabolism-Normally,blood glucose concentration is regulated at 54-108 mg/dl (3-6 mmol/dl) although many reference place the normal blood sugar
level in a fasting state is from 70-110 mg/100ml.In patients with uncontrollable diabetes, there is an abnormal increase in blood sugar level due to the absence of or
inefficient functioning insulin.Blood glucose cannot be oxidized properly in the cells to furnish energy and therefore accumulates in the blood. (hyperglycemia).When the
blood glucose level exceeds the renal threshold (about 160 to 180 g per 100 ml), glycosuria occurs resulting in the wastage of energy.
26
Protein metabolism. Accelerated breakdown of tissue protein also occurs in uncontrolled DM, which adds to the glucose level of blood and increase the amount of
nitrogen that must be excreted as a result of deamination and its excretion in the urine.
13/10/2019
nitrogen that must be excreted as a result of deamination and its excretion in the urine.
27
DIAGNOSTIC AND MONITORING TEST
28
FASTING BLOOD SUGAR TEST
29
GLUCOSE TOLERANCE TEST
measure of the ability of the patient to utilize a specific amount of glocuse.It is used to establish a diagnosis of diabetes or impaired glucose tolerance in asymptomatic
individual whose FBS is between 110 and 140 mg/dL OF plasma
30
GLYCOSYLATES HEMOGLOBIN (HBA1C) TEST
provides a good index for monitoring overall diabetes control and therapeutic decisions can be based on this value when this test determination is not available ,fasting
plasma glucose levels (FPG) may be used to identify patients with uncontrolled Type 2 DM and initiate timely intensification of therapy to avoid long-term complications
of diabetes
31
SELF-MONITORING BLOOD GLUCOSE (SMBG)
Allows persons who have diabetes to measure their blood glucose at home, adjust treatment regimens as needed, and achieve near-normal blood glucose levels.
This reduces microvascular complications of DM.
More sensitive than urine testing because blood glucose level must exceed 180-mg/100 mL before glucose spill into urine.
32
Use to confirm hypoglycemia and hyperglycemia
Help maintain blood glucose levels between 70 and 140 mg/100ml.
Fasting blood sugar should be below 100 mg/dL and postprandial (post-meal sugar) below 140 mg/dL
33
34
URINE EXAMINATION
Useful in testing the total volume, specific gravity, glucose and fatty acids.
(+) glycosuria (excretion of glucose into the urine) should be regarded as evidence of diabetes
Glucose can be tested using paper indicator, paper stick, addition of powder to the urine, adding a tablet to urine
35
Checked before meals and bedtime
Recommended urine collection is the double void method in which the patient voids the first urine sample, voids again one half later and tests the second sample
(+) fatty acids indicates incomplete oxidation of fats (ketonuria) ----requires immediate adjustment of diet and insulin
36
COMPLICATIONS
37
HYPOGLYCEMIA OR INSULIN SHOCK
A symptom of abnormalities in carbohydrate metabolism.
13/10/2019
A symptom of abnormalities in carbohydrate metabolism.
<70 mg/100 mL-mild, <50 mg- stupor
Increase in glucose due to delay in eating, omission of food or loss of food by vomiting and diarrhea, and due to an increase in exercise without modification of insulin
dosage
Profuse sweating, moist skin, pallor; uneasiness, faintness, nervous, weak and hungry, stupor and death if untreated.
38
TREATMENT
Immediate treatment of Carbohydrate is essential. <70 mg/dL ---15 g Carbohydrate is given e.g., sweetened fruit juices, soda, sugar, candy, syrup
<50 mg/dL--- IV glucose is necessary


39
HYPERGLYCEMIA/DIABETIC KETOACIDOSIS
Occurs when a person has inadequate insulin due to omission of insulin or consumption of more food than the insulin prescribed.
Body depends on fat for energy and ketones are formed.
If not handled properly, flu, colds, vomiting and diarrhea will occur. If untreated it can cause coma and death
Feeling of weakness, headache, vomiting, nausea, abdominal pain, aches; skin is hot, flushed and dry
40
TREATMENT
Small repeated doses of insulin with small carbohydrate feedings,
For diabetic coma- large doses of regular insulin with small doses repeated as needed every hour or until the sugar in the urine is reduced and blood sugar is <200
mg/dL
Dehydration-saline solution
Gastric lavage for vomiting
Sever acidosis- alkali therapy
41
Fruit juices, gruels, ginger ale, tea and broth as soon as fluids can be taken
Soft diet that contains 100-200 g Carbohydrates on 2nd day
Diet for his particular requirements on 3rd day
42
LONG-TERM COMPLICATIONS OF DIABETES
43
DIABETIC RETINOPATHY
Affects the back of the eyes where visual images are conveyed to the brain.
Very tiny, fragile blood vessels proliferate.
Early stage, vision gets blurry, but if blood vessels break and fill the eyes with blood it could cause blindness.
Can be detected by dilated eye examination
Blood glucose control, BP monitoring and regular lipid tests to prevent this.
13/10/2019
Blood glucose control, BP monitoring and regular lipid tests to prevent this.
44
DIABETIC CATARACT
An opacity of the lens that occurs when diabetes has not been controlled
Occurs commonly in elderly diabetics
45
DIABETIC NEUROPATHY
Occur in any part of the body, but especially in the peripheral nerves as in feet and legs.
Lesions of the nerves cause burning and tingling sensations and numbness or no feeling at all in severe cases.
Daily inspection of feet and proper hygiene and care should be practiced.
Wear socks or enclosed shoes to avoid harm to the feet.
Minor wounds could cause infection and could lead to amputation.
46
DIABETIC GASTROPARESIS
Partial paralysis of the nerves leading to the muscles of the stomach.
Chronic nausea, vomiting (especially of undigested food), abdominal pain (A feeling of fullness after eating just a few bites
dietary changes (low-fiber and low-residue diets and, in some cases, restrictions on fat and/or solids)


47
DIABETIC NEPHROPATHY
is a progressive kidney disease caused by angiopathy of capillaries in the kidney glomeruli. It is characterized by nephrotic syndrome and diffuse glomerulosclerosis. It is
due to longstanding diabetes mellitus, and is a prime indication for dialysis in many Western countries.
Most common is the Chronic Kidney Disease which is defined as a glomerular filtrate rate of less than 60 mL/minute


48
STAGES
1- has GFR of 90 with minor or early kidney damage.
2-when the GFR is between 60-89 when the kidney damage is mild.
3-GFR is 30-59 and moderate kidney damage.
4-GFR is between 15-29, severe kidney damage
5-kidney failure, needs dialysis
49
5 STAGES OF DIABETIC RENAL INVOLVEMENT
1.
2.
3.
4.
Glomerular hyperfunction and hypertrophy
Silent stage with normal urinary albumin excretion
Early diabetic nephropathy
Overt diabetic nephropathy
13/10/2019
4. Overt diabetic nephropathy
5. End-stage renal failure
50
Edema, foamy appearance or excessive frothing of the urine (caused by the proteinuria) ,unintentional weight gain (from fluid accumulation), anorexia (poor appetite),
nausea and vomiting, malaise (general ill feeling), fatigue, headache and frequent hiccups

51
Microalbuminuria is the increased but low urinary excretion indicating early changes in glomerular permeability
Increasing levels of albumin in urine indicates a progressive decline of glomerular function
Annual measurement of urinary albumin excretion is useful to detect the early stage of the disease.
52
CARDIOVASCULAR DISORDERS
Heart attacks, orthostatic hypertesion, and erectile dysfunction are some complications when DM is not treated properly.
53
PERIDONTAL DISEASE
Inflammation of the gums when dental plaque builds up.
Occurs because saliva production diminishes with aging especially when water drinking Is inadequate
54
DIABETIC SKIN LESIONS
Any damage to the skin of the diabetic patient will either heal slowly or will never heal at all.
A gangrenous condition might occur
Atherosclerosis and poor circulation of the blood are causative factors for delayed healing.
55
DIABETIC FOOT
A manifestation of chronic neuropathy aggravated by vascular insufficiency and infection.
Sensory loss allows tolerance of repeated trauma from tight shoes and improper weight bearing, which leads to skin breakdown, skin ulceration, tissue necrosis and
fracture.
56
MANAGEMENT AND TREATMENT
Prophylactic foot care includes properly fitting shoes, daily examination for injury, and care in the management of calluses and in nail cutting and cleaning.
Pt with foot ulcers must avoid local pressure to allow healing
Debridement and broad-spectrum antibiotics are used
Amputation may be necessary to prevent recurrent septicemia and death
57
58
MANAGEMENT OF DIABETES
To date, there is no cure for diabetes; the patient must learn to live with the disease. Glycemic control is fundamental to the management of diabetes, so is the control of
blood pressure and lipids to help promote a prolonged healthy and satisfying life.
13/10/2019
To date, there is no cure for diabetes; the patient must learn to live with the disease. Glycemic control is fundamental to the management of diabetes, so is the control of
blood pressure and lipids to help promote a prolonged healthy and satisfying life.
59
BASIC CONTROL OF DIABETES:
1. INSULIN OR ORAL HYPOGLYCAEMIC AGENTS
2. HEALTHY EATING
3. REGULAR EXERCISES SUITABLE FOR ONE’S MEDICAL CONDITION.
4. AVOID STRESS FACTORS: THE CONTROLLABLE AND THE UNCONTROLLABLE FACTORS.
60
DIABETES SELF-MANAGEMENT EDUCATION (DSME)
– IT IS THE ONGOING PROCESS OF FACILITATING THE KNOWLEDGE, SKILL, AND ABILITY NECESSARY FOR DIABETES SELF-CARE.
61
CONTENT AREAS FOR DSME ARE THE FOLLOWING:
* DESCRIBING THE DIABETES DISEASE PROCESS AND TREATMENT OPTIONS.
* INCORPORATING NUTRITIONAL MANAGEMENT INTO LIFESTYLE.
* INCORPORATING PHYSICAL ACTIVITY INTO LIFESTYLE.
62
* USING MEDICATION(S) SAFELY FOR MAXIMUM THERAPEUTIC EFFECTS.
* MONITORING BLOOD GLUCOSE AND OTHER PARAMETERS AND INTERPRETING AND USING THE RESULTS FOR SELF-MANAGEMENT DECISION MAKING.
*PREVENTING, DETECTING, AND TREATING ACUTE AND CHRONIC COMPLICATIONS.
* DEVELOPING PERSONAL STRATEGIES TO ADDRESS SOCIAL ISSUES AND CONCERNS AND TO PROMOTE HEALTH AND BEHAVIOUR CHANGE.
63
THE OVERALL OBJECTIVES OF DSME ARE TO SUPPORT INFORMED DECISION-MAKING, SELF CARE BEHAVIOURS, PROBLEM-SOLVING AND ACTIVE COLLABORATION
WITH THE HEALTH
CARE TEAM AND TO IMPROVE CLINICAL OUTCOMES, HEALTH STATUS AND QUALITY OF LIFE.
64
INSULIN
Most people with type 1 diabetes start off with at least two injections a day and may have as many as four or more, depending on your doctor’s assessment of your
need. As inconvenient as multiple injections each day may sound, research has shown that more daily insulin doses provide better control of blood glucose. And better
13/10/2019
need. As inconvenient as multiple injections each day may sound, research has shown that more daily insulin doses provide better control of blood glucose. And better
glucose control means reducing the risk of short and long-term health complications.

65
INSULIN, ORAL HYPOGLYCEMIC AGENTS AND INJECTABLES
Physiologic insulin has immediate onset; it peaks in ½-1 hour and last 2-3 hours. The diabetic patient secretes either insufficient insulin or none. When the body does
not manufacture enough insulin, the patient must resort on commercial insulin preparations. All insulin preparation available in the Philippines are made from
recombinant DNA technology.
66
67
DIFFERENT KINDS OF INSULIN
Rapid-acting
Starts to work in about 5 minutes, reaches the peak of effectiveness in about one hour and continues working for up to four hours.
Regular or Short-acting
This type of insulin begins to work in about 30 minutes, reaches the peak of effectiveness anywhere between two and three hours and continues working up to six hours.
Intermediate-acting
Usually begins to work in two to four hours, reaches the peak of effectiveness anywhere between two and three hours and continues working up to six hours.
Long-acting
Usually begins to work in six to ten hours and continues working up to 24 hours.

68
METHODS OF INSULIN THERAPY
Insulin Pen
Insulin Injections

External Insulin Pump

Implantable Insulin Pump



69
1.) INSULIN PEN
Looks like a pen.
Users must need to select the correct dose of insulin using a dial.
A plunger is pressed in order to deliver insulin to the user.
13/10/2019
A plunger is pressed in order to deliver insulin to the user.
70
2.) INSULIN INJECTIONS
Delivers insulin through the skin.
71
3.) EXTERNAL INSULIN PUMP
A needle connected to a plastic tubing that is inserted just under the skin near the abdomen.
The patient must program the insulin pump according to his/her needs
72
4.) IMPLANTABLE INSULIN PUMP
Small disc shaped pumps.
Surgically implanted. Usually on the left side of the abdomen.
Deliver small amount of insulin throughout the day.
Remote controlled.


73
74
DIETARY MANAGEMENT OF DIABETES MELLITUS
75

Proper dietary management still remains the most important factor in the treatment of Diabetes Mellitus.
Diet should be individualized to meet the patient’s specific needs, and to be effective, he/she must be aware of the rationale for the dietary restrictions.
Achieving a balance between food intake, medication (especially insulin levels) and energy expenditure is an essential prerequisite for achieving glycemic control.
The making out of the diet prescription should be determined by the physician. Patient interview, usually conducted by the dietitian, should include a carefully recorded
diet history. This includes:
* socio-economic conditions
* food attitudes
* eating habits
76
ENERGY ALLOWANCE
Energy allowance is determined based on the patient’s height, weight, BMI, age, sex, and activity.
13/10/2019
Energy allowance is determined based on the patient’s height, weight, BMI, age, sex, and activity.
Attaining the Desirable Body Weight of the patient should be the primary objective of these diet so as the actual weight of the patient should be the object of careful
analysis and control of Total Energy Intake.
77
The following is an Activity guide for calculating the Total Energy Requirement:
78
People with Type 2 diabetes tend to be overweight. In this case, nutritionally adequate caloric restrictions and moderate weight loss ( 10 – 20 lbs ) have been shown to
improve diabetes control, even if the desirable body weight is not achieved. Weight reduction should be initiated soon after Type 2 DM is diagnosed, when insulin
secretion is still adequate. Exercise, behavior modification of eating habits, and psychological support are additional strategies to improve compliance with caloric
prescription. ( Jamorabo-ruiz, Claudio and Diamonon. “Nutrition and Diet Therapy for Nursing” (2011) pp 388-389. )
79
CARBOHYDRATE ALLOWANCE

In diabetic patients, the range of carbohydrate intake should be 45–65%, instead of the normal 50 – 70%.

Foods containing CHO from whole grains, fruits, vegetables and non-fat dairy products are emphasized.

Patients should be advised to be careful in their consumption of sucrose-containing foods. Fructose, if taken in large amounts, has potential adverse effects on serum
cholesterol and low density lipoprotein cholesterol.
80
GLYCEMIC INDEX (GI)

Is the change in the blood glucose after ingestion of a particular food in comparison with the change in blood glucose after eating a standard food.
Used to quantify and compare the 2-hour glycemic response of individualized foods.

The response is influenced by the source and the form of carbohydrates and by the presence of fiber, and the length of time required for digestion and metabolism.



* foods with low glycemic index have been proposed to have potential beneficial effect in the management of DM.


13/10/2019


81
GLYCEMIC LOAD (GL)

Combination of the GI and the total carbohydrate content of an average serving of a food.

Defined as:
weighted mean of the dietary GI x (% total energy from CHO
*diets high in carbohydrates(high in GL) with low glycemic index are best for cardiovascular risk reduction.
*the brain and CNS have an absolute requirement for glucose, thus intakes of <130g/day are not recommended.
82
PROTEIN ALLOWANCE

The protein for the diabetic patient is the same as that of the normal individual.

Intake of protein above 20% may be a risk factor in developing diabetic nephropathy.

Restricted protein diets may modify the underlying glomerular injury while controlling hypertension and hyperglycemia, delay the progression of renal failure.
83
FAT ALLOWANCE
Recommendation is usually 25-30%, however higher amount can be given but should not exceed 35%.
*Diabetics are susceptible to Atherosclerosis and its complication; thus, consumption of saturated fats is limited to 1/3 or less fat calories and unsaturated fat must
provide 2/3 of the fat calories(1/3 monounsaturated, 1/3 polyunsaturated)
84
DIABETES MEAL PLAN

A meal plan for patients diagnosed with Diabetes Mellitus.

People with diabetes have to take extra care to make sure that their food is balanced with insulin and oral medications, and exercise to help manage their blood glucose
levels.

*the simplest is the plate method where the plate is divided into imaginary quarters: ¼ starches(rice, bread or pasta), ¼ for meat, fish, poultry and ½ for vegetables.
85
SAMPLE MEAL PLAN
13/10/2019
Sample patient: A 5’2” adult diabetic woman who is underweight and engaged in sedentary activities.
ht in cm = 5(12)(2.54)= 152.4
(2)(2.54)= 5.08
157.48 cm
DBW= 157.48cm – 100 (-10%)
= 57.48 – 5.748
TER = 51.73 x 30
86
Macronutrients:
CARBOHYDRATES = 1551.9kcal (0.6)
4kcal/g
PROTEIN
FAT
87
= 1551.9kcal (0.15)
4kcal/g
=1551.9kcal (0.25)
9kcal/g
DIET RX: 1551.9KCAL, CHO 232.78G, CHON 58.20G, FAT 43.12G
88
Sample Menu:
Breakfast:
Fruit
: Melon – 1 exchange(1 slice)
Protein dish : Hard Boiled Egg – 1 exchange(1 piece)
Bread
: Slice Bread – 2 exchanges(4 slices)
Butter
: Butter – 2 ½ exchanges(2 ½ teaspoons)
13/10/2019
Butter
: Butter – 2 ½ exchanges(2 ½ teaspoons)
Milk
: Evap. Undiluted – 1 exchange(½ cup)
Lunch:
Fruit
: Banana – 1exchange(1 small)
Protein dish : Bangus(sinigang) –1½ exchanges(1½ mbs)
Vegetable
: Kangkong – (-)(¼ cup)
Radish – (-)(¼ cup)
Sitao – 1 exchange(½ cup)
Rice
: Boiled Rice – 3 exchanges(1½ cups)
Dinner:
Fruit
: Banana – 1exchange(1 small)
Protein dish : Chicken Adobo – 1½ exchanges(1 med Leg)
Veg. dish
: Squash Guisado – 1 exchange(½ cup)
Rice
: Boiled rice – 3 exchanges(1½ cups)
* Cooking fats used – 2½ exchanges(2½ teaspoons)
89
ARTIFICIAL SWEETENERS
THESE CAN BE USED BY PEOPLE WITH DIABETES AND MAY HELP TO CONTROL CALORIC INTAKE AS THESE SWEETENERS DO NOT AFFECT BLOOD SUGAR LEVEL. ANY SWEETENER SHOULD BE
USED IN MODERATION.
90
SWEETENING AGENTS:
1. SACCHARIN
IS A WIDELY USED SWEETENING AGENT. IT MAY BE ADDED TO BEVERAGES
MG/DAY FOR ADULTS AND 500 MG/DAY FOR CHILDREN.
AND FOODS THAT DO NOT REQUIRE COOKING.
THE ACCEPTABLE DAILY INTAKE FOR SACCHARIN IS 1000
2. ACESULFAME-K
IS A NON-NUTRITIVE SWEETENER 200 TIMES SWEETER THAN SUCROSE AND SUITED FOR BAKING.
3. ASPARTAME
IS AN ARTIFICIAL SWEETENER WIDELY USED IN A VARIETY OF PRODUCTS AND HAS NO ADVERSE EFFECTS FOUND. US ADI IS 50 MG/KG/DAY.
91
4. SUCRALOSE
A NON-CALORIC HIGH INTENSITY SWEETENER DERIVED FROM ORDINARY SUGAR.
5. NEOTAME
T
-
USFDA
2002. I
0.1
/
.
13/10/2019
5. N
THE NEWEST NON-NUTRITIVE SWEETENER APPROVED BY THE USFDA IN 2002. ITS SAFE EXPECTED DAILY INTAKE IS 0.1 MG/KG BODY WEIGHT.
6. ALITAME
ANOTHER NUTRITIVE SWEETENER EXPECTED TO GET APPROVED FROM THE USFDA. IT CONTAINS 1.4 KCAL /G AND IS HIGHLY STABLE AND CAN WITHSTAND TEMPERATURE IN
COOKING AND BAKING.
92
5. Cyclamates
30 times as sweet as cane sugar, were used to sweeten softdrinks in Britain in 1964 and 1967, however in 1969, immediately stopped following a toxicity report on
rat.
6. Caloric or nutritive sweeteners
include sucrose, fructose and sorbitol and other sugar alcohols
7. Fructose
1.0 to 1.8 times sweeter than sucrose and it is most sweet in a slightly colder, slightly acidic food. Maximum accepted intake is 75g, often used in “diabetic”
commercial products.
93
8. Sorbitol, Mannitol and Xylitol
sugar alcohol derivatives also added to diabetic foods and drinks for sweetening purposes. Absorbed far slower into the bloodstream and considered advantageous
for diabetics. Sorbitol-2.6kcal/g; Mannitol-1.6kcal/g; Xylitol-2.4kcal/g
9. Stevia
latest sugar substitute that is closest to table sugar, but most expensive. Manufactured from Stevia leaves. Available as tablets, liquids, powders and extracts.
94
STEVIA PLANT
95
10. Fiber
current evidences suggests that high-fiber diets may offer some improvement in carbohydrate metabolism, may lower cholesterol and low density lipoprotein
cholesterol and increase the satiety effect of a meal.
11. Alcohol
may cause specific problems with hypoglycemia, neuropathy, glycemic control, obesity, hyperlipidemia. Contains 7 kcal/g, contraindicated in individuals on a
hypocaloric diet.
96
GUIDELINES
1. Alcohol should be consumed in moderation, not more than 2 equivalents of alcohol once or twice per week.
2. Individuals taking hypoglycemic meds should not drink alcohol.
3. Alcohol should only be ingested with meals to avoid potential hypoglycemic effect.
13/10/2019
3. Alcohol should only be ingested with meals to avoid potential hypoglycemic effect.
4. Alcohol and its equivalent caloric content should be calculated into the meal plan. One equivalent is equal to 90 kcal (2 fat exchanges)
5.
97
EXERCISE
98
EXERCISE (DIABETES)
Help regulate diabetes
 by promoting glucose utilization and improving blood circulation
Promote weight loss
Improve insulin sensitivity
Glucose tolerance in individuals with both types of Diabetes Mellitus
Improve glycemic control
99
RISK OF EXERCISE
FOR INDIVIDUALS WITH
DIABETES
Type I diabetic patient
Underinsulinized patients or in poorly controlled diabetes with pre-exercise blood glucose levels of 250-300 mg/dL
Increased hyperglycemia may prevail.
― Insufficient insulin  Glucose used by muscles is decreased  Liver release stored glucose to make for the muscle deficit  increased blood glucose
Arrhythmia or Myocardial Infarction
Worsening Microvascular Diabetic Complications with other artherosclerotic cardiovascular disease

100
EXERCISE FOR THOSE WHO HAVE DIABETES
Participate in either recreational or competitive physical activities
― To improve cardiovascular fitness and psychological well-being and;
― For social interaction and recreation
101
BEFORE UNDERTAKING EXERCISE:
Individual should receive a complete medical evaluation
Should be tailored to the individual’s capabilities, preferences, age, lifestyle
Aerobic exercise is recommended for Cardiovascular fitness

102
TYPE I DIABETIC
― Self Monitoring Blood Glucose (SMBG) is important in deciding when to exercise and how to treat potential hypoglycemia
13/10/2019
― Self Monitoring Blood Glucose (SMBG) is important in deciding when to exercise and how to treat potential hypoglycemia
― Should always carry diabetic identification card or a bracelet
― Should know the sources of easily available carbohydrate
― Muscles can be sensitive to insulin for up to 24 hours after exercise
― Replacement of liver and muscle glycogen stores
103
Type I Diabetic Patient who exercise at about time daily
― should have a meal plan that provides enough kcal to cover the exercise
Type I Diabetic Patient who exercise sporadically or less than daily
― may choose to lower the insulin dose and/or increase food intake to regulate blood glucose levels after consultation
104
Type 2 Diabetic Patient
―Glycemic control can improve with exercise due to increased insulin sensitivity
― Walking 2,500 steps or more per day can be helpful in losing weight and have a greater drop in blood pressure (Health Magazine)
Postprandial hyperglycemia
― Exercise after eating will be beneficial
105
DIETARY GUIDELINES FOR GESTATIONAL DIABETES
Be familiar with client’s height and weight, history of previous pregnancies, blood pressure readings, and records of blood glucose.

Emphasize 3 small meals and between-meal snacks

Fruits should be planned as mid-morning snack because the fasting blood sugar of women is usually high in the morning due to hormonal release.

106
DIETARY GUIDELINES FOR GESTATIONAL DIABETES
Choose starchy foods like whole grains and high in dietary fiber to prevent constipation.

3 servings of fruit for lunch, mid-afternoon snack, and dinner.
5-6 servings of nonstarchy dark-colored vegetables (broccoli, red lettuce, eggplant, tomatoes)
2-3 glasses of low-fat milk or equivalent and the right kind of fats and oils.

13/10/2019
Keep saturated fats under 10% of total fat.
107
DIETARY GUIDELINES FOR GESTATIONAL DIABETES
40-45% CHO, 30-35% CHON, 30-35% F

Supplements prescribed contain 600 mcg folic acid, adequate vitamin C, and other B- vitamins.

Supply iron no less than 30 mg/day.

Caution on sodium intake when there is pre-eclampsia or risks of hypertension.
108
MANAGEMENT OF DIABETES IN CHILDREN
Onset of symptoms is usually more sudden and severe, and tends to increase in severity during the period of growth.
Obesity, in contrast to adults is uncommon; in fact, most diabetic children are underweight.
All diabetic children need insulin.
Additional nutrients needed for growth and the varying activity from time to time requires frequent dietary adjustments.
109
MANAGEMENT OF DIABETES IN CHILDREN
INSULIN TREATMENT
 Requirements for insulin are often variable due to fluctuating activities (sedentary to very active).
 Execcive activity = hypoglycemia
 Lethargy (eg. From Infectious Diseases) = hyperglycemia
 Suitable combination: Depot insulin (Insulin formed in the subcutaneous tissue; long-acting) + 1 dose of soluble insulin before breakfast + 1 dose of soluble insulin
before supper

110
MANAGEMENT OF DIABETES IN CHILDREN
DIET THERAPY
 Dietary modifications same as for adults.
 Nutritive requirements same as normal child of same age, size and activity.
 Goal: Maintenance of normal growth and development.
111
MANAGEMENT OF DIABETES IN CHILDREN
112
MANAGEMENT OF DIABETES IN CHILDREN
MINERALS AND VITAMINS
13/10/2019
MINERALS AND VITAMINS
 Additional calcium requirements: 3-4 cups of milk/day
 Generously supplied with leafy green and yellow vegetables as well as appropriate cooking oil and butter or margarine (vitamins + fat).
 Problems: Fat and sodium rich foods consumption, skipping meals, eating out, alcohol consumption by some, dislike for certain vegetables and lack of professional
guidance.
