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Nutrition and Diabetes

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Title: Nutrition and Diabetes


1
Nutrition and Diabetes
  • Chapter 19 Nelms, Sucher Long
  • Insert some of my slides from Nursing course

2
Diabetes Mellitus (DM)
  • Most common endocrine disorder
  • Defects in insulin production, insulin action, or
    both
  • All types characterized by hyperglycemia (excess
    blood glucose)
  • A chronic disease of major public health
    significance amongst Canadians
  • Affecting 1.8 million Canadians (5.5 of
    population)
  • For every diabetic known, is one not yet
    diagnosed -- likely prevalence is 10 of
    population
  • WHO says over 300 million people will have
    diabetes by year 2025

3
A Serious Health Problem
  • Major cause of coronary artery disease (CAD) --
    leading cause of mortality
  • Leading cause of blindness and kidney disease
  • People with diabetes tend to have more health
    problems in middle adult years and die younger
  • Financial costs to individual and society

4
Canadian Diabetes Association Website
  • http//www.diabetes.ca
  • CDA 2008 Clinical Practice Guidelines for the
    Prevention Management of Diabetes in Canada
  • http//www.diabetes.ca/files/cpg2008/cpg-2008.pdf
  • Purchase from bookstore Beyond the Basics Poster

5
Characteristics of Diabetes
  • Either not enough insulin is produced and/or body
    does not use insulin properly
  • Glucose in blood cannot enter cells so it cannot
    be used for energy
  • Glucose accumulates in the blood (hyperglycemia)
  • Body burns protein and fat -- produces ketones
  • Ketoacidosis results can cause death

6
Types of Diabetes
  • Type 1
  • Diabetes that is primarily the result of
    pancreatic beta-cell destruction and is prone to
    ketoacidosis
  • Usually leads to absolute insulin deficiency
  • Type 2
  • Diabetes that may range from predominant insulin
    resistance with relative insulin deficiency to a
    dominant secretory defect with insulin resistance

7
Types of Diabetes
  • Type 1
  • 5-10 of diabetics are Type 1
  • Rapid onset usually during youth (before 30
    years)
  • Must take insulin daily
  • Used to be called Insulin Dependent Diabetes
    Mellitus (IDDM) or juvenile onset diabetes
  • Type 2
  • 90 - 95 of diabetics are Type 2
  • Progressive onset (usually over 40), often occurs
    in obese
  • May or may not need insulin
  • Used to be called Non-Insulin-Dependent Diabetes
    Mellitus (NIDDM) or adult onset diabetes

8
Types of Diabetes
  • Gestational Diabetes Mellitus (GDM)
  • Glucose intolerance experienced first during
    pregnancy

9
Etiology of Type 1
  • Immune mediated loss of pancreatic beta-cells
  • Due to genetic and environmental factors
  • Diabetes related auto-antibodies
  • Viruses
  • At present, no preventive measures are known to
    be effective

10
Etiology of Type 2 Diabetes
  • Factors associated with type 2 diabetes include
  • older age, family history, certain ethnic
    backgrounds, overweight/obesity (especially
    central adiposity), metabolic syndrome
    (hypertension, dyslipidemia, ), physical
    inactivity, history of GDM, overt CAD, polycystic
    ovary syndrome, history of impaired fasting
    glucose, and impaired glucose tolerance
  • Growing evidence justifies promotion of weight
    reduction/control, diet exercise

11
Long-term Complications of Diabetes
  • Macrovascular disease
  • coronary heart disease, peripheral vascular
    disease, cerebrovascular disease
  • Microvascular Disease
  • eyes, kidneys
  • Aim to maintain tight blood glucose control to
    avoid long-term vascular damage

12
Macrovascular DiseaseDyslipidemia
  • Elevated serum lipids increase risk of
    atheroscelorosis and cardiovascular disease
  • Diabetics are more likely to have elevated serum
    triglycerides and VLDL cholesterol, and lower
    levels of HDL cholesterol
  • Justification behind reducing total fat and
    saturated fat intake

13
Macrovascular DiseaseHypertension
  • Need vigorous treatment of diabetics with
    hypertension to avoid macro - and micro vascular
    diseases
  • Develops with the onset of nephropathy
  • Sodium restriction, weight reduction and
    restricted alcohol intake

14
Microvascular DiseaseRetinopathy
  • Major cause of adult blindness
  • Associated with higher glycemic levels
  • Improved glucose control slows progression of
    retinopathy
  • Elevated blood pressure high blood lipids are
    added risk factors
  • Need for careful follow-up by ophthalmalogist

15
Microvascular DiseaseNephropathy
  • Occurs in 20-40 of diabetics reason for 44 of
    new CKD cases
  • Renal dysfunction begins with increased albumin
    excretion (gt 30 mg/24h) and increased glomerular
    filtration rate (GFR)
  • Presents shortly after diagnosis but renal
    function can return to normal once glycemic
    control is restored
  • May progress to microalbuminuria (30-300 mg/24h)
    - indicates diabetic nephropathy
  • Macroalbuminuria (gt300 mg/24h) indicates overt
    nephropathy

16
Microvascular DiseaseNeuropathy
  • Functional pathologic changes in the peripheral
    nervous system
  • Effects 40-50 of Type 1 and Type 2 diabetics
    within 10 years of onset of diabetes
  • Increased risk of foot ulceration
  • need for good foot care

17
Adjustments in Metabolism
  • Diabetes causes the body to behave as if it were
    in starvation modeeven when large amounts of
    food are consumed.
  • Diabetes is due to a lack of insulin activity,
    and intensified by hypersecretion of catabolic
    hormones.

18
Action of Insulin on CHO Metabolism
  • Activates the transport system of glucose in
    muscles and adipose cells
  • Reduces breakdown and output of glucose from the
    liver glycogen
  • Enables the conversion of glucose to glycogen for
    storage in liver and muscle

19
Action of Insulin on Fat Metabolism
  • Promotes fatty acid synthesis in the liver
  • Promotes TG storage in adipose tissue
  • Reduces lipolysis in adipose tissue
  • Reduces ketogenesis in liver

20
Action of Insulin on Protein Metabolism
  • Promotes amino acid uptake into muscle adipose
    tissue lowers blood amino acid levels
  • Reduces amino acid catabolism
  • Promotes protein synthesis in muscle and adipose
    tissue to lesser extent in the liver
  • Reduces protein degradation in muscle adipose
    tissue and liver

21
Effect of Catabolic Hormones
  • Glucagon, adrenal glucocorticoids, and growth
    hormone are called catabolic hormones because
    they are antagonistic to insulin
  • Thus the diabetic is in hormonal imbalance

22
Diagnostic Criteria
  • Fasting Plasma Glucose (FPG) level of gt7.0
    mmol/L
  • or
  • Casual PG gt11.1 mmol/L symptoms of diabetes
  • Casual any time of the day, without regard to
    the interval since the last meal
  • Classic symptoms of diabetes polyuria,
    polydipsia and unexplained weight loss
  • or
  • 2hPG in a 75-g OGTT gt11.1 mmol/L
  • Must have two confirmatory test results

23
Diagnostic Criteria
  • Pre-diabetes
  • People with Fasting Plasma Glucose levels between
    6.1 and 6.9 mmol/L are considered to have
    impaired fasting glucose (IFG) and have a higher
    risk of developing diabetes and CVD
  • Need for screening and lifestyle changes
  • Plasma glucose measured 2 hours after a 75 g oral
    glucose load (2hPG) 7.8 - 11.0 mmol/L indicates
    impaired glucose tolerance (IGT)
  • Can have IFG IGT

24
Oral Glucose Tolerance Test (OGTT)
  • 150 g CHO/ day for 3 days prior to test
  • 10 to 16 hour fast, then a glucose load of 75 g
    in 300 mL beverage consumed within 5 minutes of
    fasting blood sample
  • Repeat blood samples every 30 min for 2 to 5
    hours

25
SummaryGlucose Levels for Diagnosis
26
Gestational Diabetes (GDM)
  • GDM occurs in 3.7 of all pregnancies (8-18 in
    aboriginal populations)
  • Justifies screening for all pregnant women
  • GD Screen between 24-28 weeks
  • 50 g glucose load with FPG 1 hour later
  • Diagnosis if PBG gt 10.3 mmol/L
  • Increased infant morbidity macrosomia (with
    increased risk of trauma) and neonatal
    hypoglymemia
  • Increased risk of later diabetes in mother

27
Glycated Hemoglobin Assays (A1C)
  • Blood test that measures an individuals average
    blood glucose levels for preceding 3-4 months
  • Expressed as a percentage of total hemoglobin
    that has glucose attached to it
  • A1C test not used in diagnosis
  • Measure every 3 months when glycemic targets not
    being met or when therapy adjusted
  • Every 6 months when targets achieved

28
Screening for Type 2 Diabetes
  • Mass screening in general population not
    recommended
  • Testing every 3 years for those gt 40 years
    recommended
  • More frequent for those in high risk groups
  • Overweight youth with two risk factors (family
    hx, member of certain ethnic groups, signs of
    insulin resistance) screen at 10 years of age
    every 2 years

29
Hypoglycemia
  • Low blood glucose level (lt4.0 mmol/L)
  • caused by excessive insulin or oral
    anti-hyperglycemic agents, too little food,
    delayed or skipped meals/snacks, exercise, or
    alcohol intake without food
  • Also called insulin reaction or insulin shock
  • Symptoms
  • headache, blurred vision, mood changes, seizures,
    coma
  • Corrected by ingesting glucose tablets or
    glucagon injection

30
Diabetic Ketoacidosis
  • Severe, uncontrolled diabetes, resulting from
    insufficient insulin for glucose utilization
  • Causes severe disturbances in CHO, fat and
    protein metabolism
  • Ketone bodies (acids) build up in the blood
  • Symptoms
  • Polyuria, polydipsia, dehydration, fatigue,
    vomiting, fruity odor to breath, labored
    breathing (Kussmaul respiration)
  • If not treated with insulin and fluids
    immediately, can result in coma and death

31
Management of Diabetes
  • Goal to maintain persons health
  • Prevent or delay micro and macro vascular
    complications
  • Quality of life and overall sense of well-being
  • All aspects of everyday life affected by
    treatment ? client key member of DHC team
  • Includes
  • food intake
  • medication
  • insulin
  • oral anti-hyperglycemic drugs
  • exercise
  • self-monitoring of blood glucose (SMBG)
  • laboratory tests
  • self-management training

32
Oral Glucose-Lowering Medications
  • Also referred to as oral hypoglycemic agents/oral
    anti-hyperglycemic agents
  • Used to help control blood glucose levels in Type
    2 diabetes
  • Initiated when lifestyle changes have failed to
    achieve target glucose levels in 2 to 3 months
  • Aim to attain target A1C within 6-12 months
  • May use 2 or more in combination
  • As endogenous insulin declines, can use insulin
    along with oral medications

33
Oral Glucose-Lowering Medications
  • Sulfonylureas
  • stimulate pancreas to release insulin
  • Meglitinide
  • new class which increases pancreatic secretion of
    insulin, quick acting and can be taken before
    meals
  • Biguanides
  • decrease liver glucose production, delay glucose
    absorption and enhance glucose uptake
  • Alpha-glucosidase inhibitors
  • slows down absorption of starch and sucrose in
    small intestine
  • Thiazolidinediones
  • Lowers insulin resistance and enhances insulin
    action in cells

34
Insulin Therapy
  • Insulin formulations classified according to
    their duration of action as well as time of onset
    peak activity.
  • Types of Insulin Preparations
  • Long acting insulin best used as background
    (basal) insulin
  • NPH, Lente, Ultralente
  • Short acting insulin
  • Regular, Toronto quickly absorbed and best
    used at mealtime
  • Rapid acting insulin
  • Novorapid, lispro (Humalog) rapidly absorbed and
    best used at mealtime

35
Types of Insulin and Their Actions
36
Insulin Protocols
  • Adapt to tx goals, lifestyle, diet, age, general
    health, motivation, capacity for hypoglycemia
    awareness, social/financial circumstances
  • Multiple daily injections (3-4)
  • basal-bolus I.e. regular or lispro insulin
    before each meal and NPH or lente for basal
    action
  • Insulin pen devices
  • Continuous Subcutaneous Insulin Infusion (CSII)
    or Insulin Pump Therapy
  • 2 Injections per day
  • split-mixed i.e. mixture of regular and NPH
    before breakfast and bedtime
  • Single injection
  • NPH at bedtime with oral agents during day (type
    2 only)

37
Target Glucose Levels
Ideal Optimal (target goal) Suboptimal (action may be req.) Inadequate
Glycated Hb lt100 (.04-.06) lt115 (lt0.07) 116-140 (0.07-0.084) gt 140 (gt0.084)
FBG mmol/L 3.8-6.1 4-7 7.1-10 gt10
Post-prandial 4.4-7 5.0-11 11.1-14 gt14
38
Self Blood Glucose Monitoring (SBGM)
  • Monitoring daily changes
  • Improves blood glucose control
  • Help ID hypoglycemia
  • Assess effects of diet, exercise, and treatment
    changes
  • Frequency weigh benefits to costs
  • Type 2 diet OHA fasting and postmeal
  • Type 1 premeal and bedtime intermittent
    postmeal

39
Dietary Management of Diabetes
  • Goals
  • Maintain or improve quality of life nutritional
    physiological health
  • Achieve recommended serum blood lipid levels
  • Nutrition therapy reduces A1C by 1-2
  • Prevent and treat acute long-term
    diabetes-related complications, associated
    conditions disorders
  • Enhance over all health

40
Dietary Management of Diabetes
  • Approaches
  • Diabetes Self Management Education
  • Comprehensive nutrition assessment essential
  • Self-care treatment plan
  • Consider
  • health status
  • learning ability
  • readiness to change
  • current lifestyle

41
Nutrition Goals for Type 1
  • Consider intensive insulin therapy to allow
    flexibility in meal patterns
  • Integrate insulin therapy with usual food
    intake/eating pattern
  • May need consistent mealtime/carbohydrate amounts
    depending on insulin regime (conventional
    therapy)
  • Monitor blood glucose levels before bed
    pre-meal
  • gt3 times daily correlated with best control

42
Nutrition Goals for Type 2
  • Weight loss for those with BMI gt25kg/m2
  • Space meals throughout day
  • Avoid excessive CHO intake at one meal
  • May need consistent mealtime depending on insulin
    use or insulin secretagogues
  • Physical activity

43
Dietary Management of Diabetes Guidelines
  • CHO gt45 of energy
  • gt 60 from low GI high-fibre CHO
  • Total fat lt 35
  • Saturated -- lt 7 of total energy trans to
    minimum
  • Emphasize monounsaturated fats
  • Protein 10 - 20 of total energy intake
  • Fibre 25-50 grams/day (higher than general
    population)

44
Dietary Management of Diabetes Guidelines
  • Carbohydrates and Sweeteners
  • Amount and source have effect on postprandial
    blood glucose
  • Emphasis on total CHO rather than simple or
    complex
  • Different foods have different effects on blood
    sugar level -- glycemic index
  • Can have sucrose as part of CHO allotment up to a
    maximum of 10 of calories
  • Replacement not addition
  • Low nutrient value

45
CHO Source Glycemic Index (GI)
  • An indicator ranking carbohydrate rich foods by
    how much they raise blood glucose levels compared
    to a standard food (glucose or white bread)
  • Foods with a low GI are digested and absorbed
    more slowly than foods with a high GI
  • Low GI foods increase amount of CHO entering
    colon and increase fermentation
  • Used for making food choices by diabetics and
    people with impaired glucose tolerance

46
CHO Source Glycemic Index (GI)
  • Low GI (55 or less)
  • Medium GI (56-69)
  • High GI (70 or more)

47
Glycemic Index Value Examples
  • Food
  • bread
  • milk
  • sucrose
  • orange juice
  • Glycemic Index
  • 100
  • 39
  • 87
  • 74

48
CHO Counting
  • Identify foods that contain CHO
  • Count CHO eaten (subtract dietary fibre from
    total CHO)
  • Add total CHO provided at each meal/snack
  • Keep consistent CHO to determine insulin bolus
  • Establish a CHOinsulin ratio
  • Label reading is an essential skill

49
Artificial Sweeteners
  • Sugar alcohols (sorbitol, mannitol, xylitol)
    cause less rise in blood glucose
  • gt10g/day may cause GI upset
  • Non-nutritive Sweeteners
  • Aspartame (Equal, Nutrasweet)
  • Sucralose (Splenda)
  • Acesulfame Potassium (Sunet)
  • Saccharin (Sweetn Low, Sugar Twin)
  • Cylamates (Sucaryl)
  • Both of these not recommended during pregnancy

50
Individualized Menu Planning
  • Client needs individualized menu and education
  • Dietitian completes nutritional assessment and
    formulates a meal plan
  • Stress flexibility
  • Canadian Diabetes Association Just the Basics,
    Healthy Eating for Diabetes Management
    Prevention

51
Diabetic Exchange System
  • Are tools for enabling food choices based on
    categories of foods and serving sizes
  • Patients need to be fairly literate
  • Carbohydrate containing foods are provided in
    serving sizes containing 15g of CHO
  • Grains and starches
  • Fruits
  • Milk Alternatives
  • Other Choices
  • Non-CHO containing foods
  • Meat alternatives
  • Fats
  • Extras
  • Canadian Diabetes Association Beyond the Basics

52
Priorities for Meal Planning
  • Type 2 diabetes with no insulin
  • Gradually reduce total saturated fat
  • Spread calories throughout the day
  • Avoid large amount of food at one time
  • Space meals at least 4-5 hours apart
  • Aim for healthy body weight
  • Promote appropriate exercise

53
Priorities for Meal Planning
  • If require insulin
  • Timing of meals and snacks important
  • Quantity and quality of food important
  • Watch CHO content
  • Snacks at time of peak insulin action
  • With more intensive use of insulin (including
    regular
  • insulin before meals)
  • Have more flexibility in food and timing
  • Match insulin to CHO consumed (CHO counting)

54
Alcohol Intake
  • Alcohol
  • Moderate amounts can be consumed when diabetes is
    well controlled
  • No more than two drinks per day
  • lt 14 standard drinks/week for men
  • lt 9 standard drinks/week for women
  • Should always take alcohol with food
  • Risk for hypoglycemia often delayed
  • Blocks gluconeogenesis interferes with
    counter-regulatory mechanisms for insulin
  • Further compounded by masking hypoglycemia
    symptoms impairing judgement

55
Some Special Situations
  • Delayed meals
  • Eat a snack if expect meal will be delayed
  • Carry available source of CHO i.e. Glucose
    tablets or hard candy to avoid hypoglycemic
    reaction

56
Some Special Situations
  • Strenuous exercise
  • Eat extra food before activity and take 15-30
    grams of CHO for every 30 min of strenuous
    activity (15 g CHO for each hour of less
    strenuous exercise)
  • Eat hearty snack after activity
  • If activity is pre-planned may reduce insulin
    dosage prior to activity

57
Some Special Situations
  • Illness
  • Lack of appetite often with illness
  • Substitute foods that are well tolerated
  • Drink sugar containing liquids
  • For each missed meal give 45-60 g CHO in small
    frequent feedings over 3-4 hours
  • I.e. soup, Jello, pop, juices, ice cream
  • Continue taking insulin!
  • Monitor blood glucose test urine ketones

58
Hypoglycemia Treatment
  • 151515 rule
  • Give quickly absorbed CHO immediately (1/2 cup
    pop or juice, 2 sugar cubes, 6-7 lifesavers, 15 g
    glucose tablets)
  • Check blood glucose after 15 minutes if still
    low repeat treatment
  • If blood glucose normalizes but individual not
    going to eat within hour, has recently exercised
    or will go to bed additional food will be needed
  • If unconscious give intravenous glucose or
    glucagon injection

59
Diabetes in Children
  • 75 of Type 1 diabetes occurs before 18 years
  • Peak onset is 6 -11 years
  • Balance between allowing for normal growth and
    development, need for glycemic control
  • Need meal plan that fits childs lifestyle and
    promotes optimal compliance

60
Management Goals in Children
  • Support normal growth and development
  • Control blood glucose
  • Prevent acute and chronic complications
  • Achieve optimal nutritional status

61
Gestational Diabetes
  • Nutrition management similar to Type 1 and Type
    2.
  • Diet tends to be slightly lower in CHO and higher
    in protein and fat (30-35)
  • Requires individualized approach

62
Reactive Hypoglycemia
  • Hypoglycemia following a meal due to rapid
    release of insulin
  • Often associated with GI surgery, particularly
    gastrectomy with dumping syndrome
  • Treatment
  • Slow gastric emptying intestinal motility
  • Small, frequent meals of complex CHO, fibre, a
    protein source
  • Avoid simple carbohydrates alcohol

63
Psychological Aspects
  • Adjustment problems
  • Beliefs regarding how serious and controllable
    disease is
  • Depression
  • Twice as common in diabetics than general
    population
  • Anxiety
  • Some evidence to show prevalence elevated
  • Eating Disorders
  • Adolescent females young women with Type 1

64
Diabetes Care
  • Diabetes Health Care (DHC) Team
  • Physician and diabetes educators
  • Other health professionals
  • Shared care ongoing communication
    participation of team members
  • Organizational aspects
  • Centralized, computerized database
  • Reminders recalls

65
Diabetes Care
  • Models of Care
  • Patient centred
  • Self-management
  • Ongoing education
  • Comprehensive care

66
Diabetes Care
  • Diabetes education
  • One-on-one, group, sustained
  • Interactive
  • Solutions focused
  • Based on experience of learner
  • Tailored to individual needs abilities

67
Diabetes Care
  • Counseling
  • Motivational Interviewing explore resolve
    ambivalence self generated arguments for change
  • Express empathy
  • Develop discrepancies
  • Roll with resistance
  • Support self-efficacy
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