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Nutrition for Patients with Diabetes Mellitus
Chapter 19
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Nutrition for Patients With Diabetes Mellitus
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Glucose circulating in the blood is a source of ready fuel for body cells
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The amount of carbohydrate consumed and, to a lesser extent, the type of carbohydrate eaten
are the primary determinants of how quickly and how high blood glucose levels rise after eating
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A rise in postprandial blood glucose levels stimulates the pancreas to secrete insulin
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Fasting blood glucose levels over 126 mg/dL indicate diabetes
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Diabetes
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Diabetes is one of the most costly and burdensome chronic diseases of our time
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Increasing in epidemic proportions
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The estimated direct and indirect cost associated with diabetes in 2007 was $174 billion
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The CDC estimates that one in three children born in the U.S. in 2000 will have diabetes in his or
her lifetime; for Hispanics, the estimate is one out of two
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Diabetes (cont’d)
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Type 1 diabetes
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Formerly known as insulin-dependent diabetes mellitus
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Characterized by the absence of insulin
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Risk factors for type 1 diabetes may be:
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Autoimmune
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Genetic
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Environmental
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Diabetes (cont’d)
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Type 1 diabetes (cont’d)
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No known way to prevent type 1 diabetes
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All people with type 1 diabetes require exogenous insulin to control blood glucose levels
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Most often detected in children, adolescents, and young adults
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Classic symptoms of polyuria, polydipsia, and polyphagia
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Diabetes (cont’d)
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Type 2 diabetes
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Occurs most often after the age of 45
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Accounts for 90% to 95% of diagnosed cases of diabetes
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A slowly progressive disease that usually begins as a problem of insulin resistance
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Type 2 diabetes is often asymptomatic
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Diabetes (cont’d)
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Type 2 diabetes (cont’d)
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Insulin resistance is strongly linked to obesity
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Risk factors for type 2 diabetes
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Age 45 years or older
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Overweight (BMI ≥25 kg/m2)
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First-degree relative with diabetes
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Physically inactive or exercises fewer than 3 times/week
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Diabetes (cont’d)
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Risk factors for type 2 diabetes (cont’d)
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Member of high-risk ethnic group: African American, Latino, Native American, Asian
American, Pacific Islander
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Previously identified with prediabetes such as impaired fasting glucose or impaired
glucose tolerance
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History of gestational diabetes or giving birth to a baby weighing more than 9 pounds
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Hypertensive
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HDL <35 mg/dL and/or triglyceride level ≥250 mg/dL
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Diabetes (cont’d)
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Many of the risks for type 2 diabetes are characteristics of metabolic syndrome (MetS)
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People with MetS are twice as likely to develop heart disease and five times as likely to
develop diabetes compared to those without
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Estimated that more than two thirds of people with type 2 diabetes have metabolic
syndrome
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Even modest weight loss can lessen the risks associated with metabolic syndrome
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Diabetes (cont’d)
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Modifiable risk factors for metabolic syndrome include excess body fat, a sedentary lifestyle,
and a high–saturated-fat diet
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Diabetes (cont’d)
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Gestational diabetes
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Hyperglycemia that develops during pregnancy
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Risk factors:
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A family history of gestational diabetes
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Obesity, being a member of a certain ethnic population (Native Americans,
Hispanic Americans, Mexican Americans, African Americans, Asian Americans,
and Pacific Islanders)
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A history of giving birth to an infant weighing more than 9 pounds
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Diabetes (cont’d)
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Gestational diabetes (cont’d)
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All women are routinely screened between 24 and 28 weeks’ gestation
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Immediately after pregnancy, 5% to 10% of women with gestational diabetes are
diagnosed with diabetes, usually type 2
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Question
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Type 1 diabetes, once referred to as insulin- dependent diabetes, is caused by what?
a. Hyperinsulinemia
b. Absence of insulin
c. Sensitivity to insulin
d. Metabolic syndrome
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Answer
b. Absence of insulin
Rationale: Type 1 diabetes, formerly known as insulin-dependent diabetes mellitus, is
characterized by the absence of insulin.
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Acute Diabetes Complications
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Untreated or poorly controlled diabetes can lead to acute life-threatening complications
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Conversely, hypoglycemia caused by overuse of medication, too little food, or too much
exercise, can also be life threatening
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Acute Diabetes Complications (cont’d)
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Diabetic ketoacidosis (DKA)
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People with type 1 diabetes are susceptible to diabetic ketoacidosis (DKA)
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Characterized by hyperglycemia (glucose levels >250 mg/dL) and ketonemia
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Caused by a severe deficiency of insulin or from physiologic stress, such as illness or
infection
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Acute Diabetes Complications (cont’d)
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Diabetic ketoacidosis (DKA) (cont’d)
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Polyuria may lead to dehydration, electrolyte depletion, and hypotension
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Hyperventilation occurs in an attempt to correct acidosis by increasing expiration of
carbon dioxide
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Fatigue, nausea, vomiting, and confusion develop
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Diabetic coma and death are possible
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Acute Diabetes Complications (cont’d)
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Diabetic ketoacidosis (DKA) (cont’d)
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DKA is sometimes the presenting symptom when type 1 diabetes is diagnosed
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DKA rarely develops in people with type 2 diabetes
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DKA is treated with electrolytes, fluid, and insulin
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Acute Diabetes Complications (cont’d)
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Hyperosmolar hyperglycemic nonketotic syndrome (HHNS)
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Characterized by hyperglycemia (>600 mg/dL) without significant ketonemia
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Occurs most commonly in people with type 2 diabetes
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Dehydration and heat exposure increase the risk
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Illness or infection is usually the precipitating factor
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Acute Diabetes Complications (cont’d)
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Hyperosmolar hyperglycemic nonketotic syndrome (HHNS) (cont’d)
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Older people may be particularly vulnerable
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Develops relatively slowly
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Symptoms
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Best protection against HHNS is regular glucose monitoring
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Treatment includes insulin and fluid and electrolyte replacement
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Acute Diabetes Complications (cont’d)
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Hypoglycemia
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Blood glucose level less than 70 mg/dL
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Commonly referred to as “insulin reaction”
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Occurs from taking too much insulin, inadequate food intake, delayed or skipped meals,
extra physical activity, or consumption of alcohol without food
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Symptoms
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Acute Diabetes Complications (cont’d)
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Hypoglycemia (cont’d)
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Mild hypoglycemia is treated with 15 to 20 g of glucose
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Symptoms normally improve in 10 to 20 minutes
Hypoglycemic unawareness
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Consistent monitoring of blood glucose is especially important
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Question
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Is the following statement true or false?
Diabetic ketoacidosis is characterized by glucose levels greater than 250 mg/dL.
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Answer
True.
Rationale: People with type 1 diabetes are susceptible to diabetic ketoacidosis (DKA),
characterized by hyperglycemia (glucose levels >250 mg/dL) and ketonemia.
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Long-Term Complications
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Retinopathy
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Nephropathy
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Neuropathy
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Myocardial infarction
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Stroke
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Peripheral vascular disease
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Long-Term Complications (cont’d)
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Mild to severe forms of nervous system damage
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Impaired wound healing
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Periodontal disease
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Pregnancy complications
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Increased susceptibility to other illnesses
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Diabetes Management
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Type 1 diabetes
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Type 2 diabetes
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Managed by a coordinated regimen of nutrition therapy and insulin
Diet and exercise
Goals and interventions are specified for 3 levels of prevention:
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Primary prevention of diabetes among people with prediabetes or at high risk of
diabetes
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Secondary prevention of managing existing diabetes
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Tertiary prevention of slowing the rate of diabetes complications
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Diabetes Management (cont’d)
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Calories, overweight, and obesity
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Weight loss has traditionally been the focus of nutrition intervention for overweight and
obese people with prediabetes or type 2 diabetes
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No one proven strategy that can be uniformly recommended to promote weight
loss in all clients
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Weight loss medications
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Bariatric surgery
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Diabetes Management (cont’d)
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Preventing diabetes
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Weight loss through a combination of healthy eating and exercise is the primary focus of
diabetes prevention
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Diabetes Prevention Program (DPP)
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A low–saturated-fat intake may reduce the risk for diabetes by improving insulin
resistance and promoting weight loss
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Several studies show that an increased intake of whole grains and fiber lower the risk of
diabetes
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Diabetes Management (cont’d)
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Secondary prevention: managing diabetes
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Primary goal of diabetes management is to keep blood glucose levels as near normal as
possible
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Secondary goals
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Attain and maintain control of blood lipid levels and blood pressure
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Prevent or delay the development of complications
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Meet the individual’s cultural and personal needs
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Maintain the pleasure of eating by not limiting any foods unless indicated by
scientific evidence
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Diabetes Management (cont’d)
Secondary prevention: managing diabetes (cont’d)
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Nutrition therapy is an essential component of diabetes management
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Coronary heart disease (CHD) is the leading cause of death among people with diabetes
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Total carbohydrates
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RDA for carbohydrates is 130 g/day
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Acceptable macronutrient distribution range (AMDR) is 45% to 65% of total
calories
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Diabetes Management (cont’d)
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Secondary prevention: managing diabetes (cont’d)
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Total carbohydrates (cont’d)
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Glycemic control depends on matching carbohydrate intake with the action of
insulin or other medication
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A low–glycemic-index diet may provide a modest benefit in controlling
postprandial hyperglycemia
Sweeteners
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Sucrose and sucrose-containing foods are not restricted
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Foods high in sugar are usually nutrient poor
Diabetes Management (cont’d)
Secondary prevention: managing diabetes (cont’d)
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Sweeteners (cont’d)
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Use of fructose as an added sweetener is not recommended
 May adversely affect serum lipid levels
 No reason for people with diabetes to avoid naturally occurring fructose
in fruit and vegetables
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Diabetes Management (cont’d)
Secondary prevention: managing diabetes (cont’d)
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Sugar alcohols
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Provide fewer calories and cause a smaller increase in glucose
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Do not contribute to dental cavities
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Nonnutritive sweeteners
 Saccharin, aspartame, acesulfame, sucralose, and neotame
 May safely be used by people with diabetes
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Diabetes Management (cont’d)
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Secondary prevention: managing diabetes (cont’d)
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Fiber
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Recommendations for fiber are the same as for the general population
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Foods rich in fiber provide other benefits such as increasing satiety; providing
vitamins, minerals and phytochemicals; and lowering serum cholesterol levels
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Diabetes Management (cont’d)
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Secondary prevention: managing diabetes (cont’d)
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Fat
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People with diabetes appear to have the same cardiovascular risk as people
with preexisting cardiovascular disease
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People with diabetes are advised to limit their intake of saturated fat to less
than 7% of total calories, minimize their intake of trans fat, and consume less
than 200 mg of cholesterol daily
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Little difference from AHA recommendations
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Diabetes Management (cont’d)
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Secondary prevention: managing diabetes (cont’d)
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Protein
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In the American diet, protein provides 15% of total calories
Alcohol
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Moderate use of alcohol (1 drink/day or less in women and 2 drinks/day or less
in men) by people who have well-controlled diabetes minimally affects blood
glucose and insulin levels
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Diabetes Management (cont’d)
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Secondary prevention: managing diabetes (cont’d)
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Vitamins and minerals
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Vitamin and mineral requirements of people with diabetes are no different from
those of the general population
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Uncontrolled diabetes is often associated with micronutrient deficiencies
 Treatment is a balanced diet that supplies natural sources of nutrients
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Chromium
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Diabetes Management (cont’d)
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Tertiary prevention: controlling diabetes complications
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Progression of microvascular diabetes complications may be modified by improving
glycemic control and lowering blood pressure
Meal planning approaches
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Monitoring carbohydrate intake is key to controlling blood glucose levels
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Meal plan should reflect the individual’s lifestyle, preferences, and willingness/ability to
make dietary changes
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Diabetes Management (cont’d)
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Meal planning approaches (cont’d)
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Exchange lists for meal planning
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Choose Your Foods: Exchange Lists for Meal Planning is a framework for
choosing a healthy diet
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Groups foods into lists that, per serving size given, are similar in carbohydrate,
protein, fat, and calories, based on rounded averages
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Three major categories are Carbohydrates; Meat and Meat Substitutes; and Fats
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Diabetes Management (cont’d)
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Exchange lists for meal planning (cont’d)
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Sample meal pattern is designed for clients based on their usual pattern of eating
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Clients are encouraged to eat a variety of foods within each list and to make healthy
choices
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Food should be weighed or measured until portion sizes can be accurately estimated
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Eliminates the need for daily calculations
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Diabetes Management (cont’d)
Exchange lists for meal planning (cont’d)
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Some items on some lists are counted as more than just one choice or one exchange
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Some items appear on more than 1 list and in different amounts
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Best suited to people who want or need structured meal-planning guidance and are able
to understand complex details
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Carbohydrate counting
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Easier and more flexible alternative to using the exchange system
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Clients are given an individualized meal pattern that specifies the number of
carbohydrate “choices” for each meal and snack
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Carbohydrate choice lists
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Protein and fat cannot be disregarded
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Diabetes Management (cont’d)
Diabetes Management (cont’d)
Carbohydrate counting (cont’d)
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Appropriate for people who understand the importance of consuming a consistent
carbohydrate intake to match insulin or medication peaks
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Feel more in control and benefit from improved glucose control
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Keeping records of blood glucose tests and food intake helps
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Diabetes Management (cont’d)
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Changing behaviors
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Diagnosis of diabetes often triggers anxiety and uncertainty
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Before recommending dietary changes, it may be useful to ask the client:
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What are your goals for nutrition counseling?
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What behaviors do you want to change?
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What changes can you make in your present lifestyle?
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Diabetes Management (cont’d)
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Changing behaviors (cont’d)
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Before recommending dietary changes, it may be useful to ask (cont’d):
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What obstacles may prevent you from making changes?
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What changes are you willing to make right now?
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What changes would be difficult for you to make?
Diabetes Management (cont’d)
Changing behaviors (cont’d)
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Ideally, positive changes occur progressively
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Patient actively involved in goal setting, self-monitoring, and recordkeeping
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Periodic and ongoing follow-up improves compliance
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Question
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Is the following statement true or false?
Sugar alcohols do not contribute to dental cavities.
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True.
Answer
Rationale: Sugar alcohols do not contribute to dental cavities yet using them is not likely to
produce weight loss or improve glycemic control.
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Pharmacologic Management of Diabetes
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People with type 1 diabetes rely on exogenous insulin for survival
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Due to the progressive nature of the disease, most people with type 2 diabetes eventually
require oral agents, insulin, or a combination of both to manage blood glucose levels
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Pharmacologic Management of Diabetes (cont’d)
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Insulin therapy for people with type 1 diabetes
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Insulin preparations vary in how quickly they act, when their peak action occurs, and
how long their effects last
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Intermediate- or long-acting insulin is used to meet basal needs
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Rapid- or short-acting insulin is used before each meal
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Closely resembles how insulin is normally secreted
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Nighttime hypoglycemia can be a problem with NPH peaking during the night
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Pharmacologic Management of Diabetes (cont’d)
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Intensive insulin therapy for people with type 1 diabetes (cont’d)
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Popular and dynamic insulin regimen for type 1 diabetes
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Algorithm gives formulas for clients to calculate the carbohydrate-to-insulin ratio for the
anticipated carbohydrate content of a meal/snack
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Requires more calculations at each meal but allows greater flexibility in when meals are
eaten and how much carbohydrate is consumed
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Pharmacologic Management of Diabetes (cont’d)
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Insulin therapy for people with type 2 diabetes
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Approximately 30% of people with type 2 diabetes eventually require insulin
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Often begins with a single injection of intermediate- or long-acting insulin at bedtime
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Another regimen uses a morning injection of rapid and intermediate-acting insulin with
an intermediate- or long-acting insulin at dinner or before bedtime
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Self-monitoring of blood glucose levels
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Pharmacologic Management of Diabetes (cont’d)
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Glucose lowering medications
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Oral glucose lowering medications vary in their mechanism of action and food concerns
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Considered adjunct to nutrition therapy and exercise, not a sole mode of therapy
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Exercise
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An important aspect of treatment for both types of diabetes
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Unless it is contraindicated for other medical reasons, the client should exercise every day
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Exercise (cont’d)
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Exercise in insulin users
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Has not been shown to improve glycemic control in type 1 diabetics
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May worsen hyperglycemia
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Should occur within 2 hours of eating
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If exercise is unplanned, an additional 10 to 15 g of carbohydrate per hour of moderate
activity is recommended
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Exercise (cont’d)
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Exercise in type 2 diabetes
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Offers substantial benefits
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Helps to maintain long-term weight reduction
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Monitor blood glucose levels
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Should occur within 2 hours after eating
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Stop activity if signs and symptoms of hypoglycemia develop
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Sick Day Management
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Acute illnesses can significantly raise blood glucose levels
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Maintain normal medication schedule, monitor blood glucose levels every 2 to 4 hours, and
maintain an adequate fluid intake
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A daily intake of 150 to 200 g of carbohydrates, approximately 45 to 50 g every 3 to 4 hours, is
recommended
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Life Cycle Considerations
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Children and adolescents
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Children with diabetes appear to have the same nutrient needs as their age-matched
peers
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Managing diabetes in children and adolescents is complicated by the impact of growth
on nutrient needs, irregular eating patterns, and erratic activity levels
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Failure to provide adequate calories and nutrients results in poor growth, as does poor
glycemic control and inadequate insulin administration
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Life Cycle Considerations (cont’d)
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Children and adolescents (cont’d)
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Individualized meal plans and intensive insulin regimens can provide flexibility for erratic
eating, activity, and growth
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Annually, 3,700 American youths are diagnosed with type 2 diabetes
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Weight control is key to preventing type 2 diabetes in children
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Life Cycle Considerations (cont’d)
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Diabetes in later life
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Unique considerations related to aging that affect glycemic control
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Blood glucose levels rise with age for reasons that are unclear
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Cognitive impairments may preclude self-management
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Older adults may be at greater nutritional risk for a variety of reasons
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A fasting target level of 120 to 150 mg/dL may be considered appropriate
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Diabetic Diets in the Hospital
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A consistent-carbohydrate diet
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Appropriate modifications in fat intake are made
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Consistent timing of meals and snacks is stressed
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No one way to provide adequate nutrition for diabetics in the hospital