PAMANTASAN NG LUNGSOD NG MAYNILA (University of the City of Manila) Intramuros, Manila College of Nursing NUTRITION AND DIET THERAPY Week 5 Nutrition for Diabetes Mellitus Learning objectives Define diabetes mellitus Identify the role of vitamin D in the onset of diabetes Compare and contrast type one diabetes with type 2 diabetes Explain the main goal of diabetes treatment and how it can be achieved Describe the current nutrition therapy guidelines Identify groups for whom special care and individualized goals are needed Discussion Diabetes mellitus represents a group of conditions characterized by either a relative or complete lack of insulin secretion by the beta cells of the pancreas or by the effects of cell insulin receptors , which results in disturbances of carbohydrates, protein, and lipid metabolism. Diabetes Mellitus is usually diagnose by elevated fasting blood glucose values, hemoglobin A 1c or more , a random blood glucose level more than 200 milligrams per dL,or a blood glucose of more than 200 milligrams per dL, 2 hours after eating. The main goal of treatment is achievement of insulin or glucose homeostasis. Diabetes mellitus is associated with disability and premature death because of the disease effect on structural and functional alteration in many body system, especially large and small blood vessels. Vitamin D and Diabetes Vitamin D deficiency is linked to the onset of diabetes through its role in maintaining the normal release of insulin buy beta cells of the pancreas. This deficiency contributes to both forms and diabetes. Vitamin D plays a significant role in maintaining the epigenome, reducing inflammation that leads to insulin resistance, and protecting the beta cells against Destruction. Vitamin D synthesis takes place in the skin because of solar ultraviolet B radiation. Because serum levels of vitamin D are low in many breastfeeding mothers, especially dark-skinned women and those who are covered, it is prudent to ensure adequate supplementation. Prediabetes and insulin resistance Doctors use the term prediabetes to indicate that blood glucose levels are higher than normal but not high enough for a diagnosis of diabetes. Insulin resistance, muscles, fat, and liver cells do not respond properly to insulin and cannot easily absorb glucose from the bloodstream. The body then needs higher level of insulin to help glucose enter the cells. Excess body fats increased the risk for insulin resistance and prediabetes; obese men and women, respectively, have a 7-fold and 12-fold higher risk for developing type 2 diabetes. A person with certain risk factor is more likely to develop prediabetes and type 2 diabetes. Being older than age 45, overweight or obese, leading a sedentary lifestyle, or having a family history of diabetes or certain ethnic background like African American, Hispanic or Latino, American Indian, Asian American, or Pacific Islander. Women who have a history of diabetes while pregnant or what you call gestationaldiabetes,Or having given birth to a baby weighing 9 pounds or more are also at risk. There are ways to prevent or delay progression to type 2 diabetes through lifestyle intervention. The national diabetes prevention program connect individual with prediabetes and train coaches who discuss food choices physical activity and coping skills. Complication Everyone with diabetes it is vulnerable to long-term complications and premature death. Many of these complications may be preempted with control of hyperglycemia. Macrovascular effects of diabetes increase the risk of coronary artery disease, peripheral vascular disease, and stroke. Cardiovascular disease this often established by the time diabetes is diagnose. Micro vascular effects include nephropathy, retinopathy, and neuropathy. with nephropathy chronic kidney disease and renal failure requiring dialysis developed in approximately half of all individuals with type one diabetes. Retinopathy from diabetes is the leading cause of blindness in North America. Neuropathy affects peripheral circulation, causing decreased sensation in extremities that may result in injury without the patient’s knowledge. Healing is impaired because of the effect of diabetes on the circulatory system. Autonomic effects may include orthostatic hypotension, persistent tachycardia, gastroparesis, neurogenic bladder, impotence, and impairment of visceral pain sensation that can obscure symptoms of angina pectoris or myocardial infarction. Criteria for Diagnosing Diabetes and Prediabetes Types A1C diabetes prediabetes 6.5 or above 5.7 to 6.4 fasting plasma oral glucose glucose (mg/dL) tolerance test (mg/dL) 126 or above 200 or above 100 to 125 140 to 199 normal about 5 99 or below 139 or below Information from Nutritional Foundation and clinical Application from Grodner,EscottStamp,Dorner Metabolic goals in Diabetes Management Glycemic control less than 7% hemoglobin A1C Preprandialcapillary plasma glucose mg/dL 90 to 130 peak postprandial capillary plasma glucose less than 180 mg/dL Cardiovascular blood pressure mmHg less than 139 / 80 triglycerides mg/dL less than 150 low density lipoprotein cholesterol mg/dL less than 100 High density lipoprotein cholesterol mg/dL males greater than 40 females greater than 50 Information from Nutritional Foundation and clinical Application from Grodner,EscottStamp,Dorner Type 1 DIABETES MELLITUS Let's learn more about diabetes mellitus type 1 ! an autoimmune disease resulting in beta cell destruction. Autoantibodies to beta cell proteins form after autoimmune destruction of the betacells. The rate of better cell destruction is variable, being rapid in infant and children and slow in adult. So individual 20 years of age or younger I'm mostly affected also called insulin dependent or juvenile diabetes onset is sudden cells use glucose for energy and without indigenous insulin, they literally begin to starve. The body responds by sending signals to eat because cells are hungry, but because glucose cannot enter cells, it builds up in the bloodstream. It is common for the person to experience weight loss while consuming large quantities of food (Polyphagia). because glucose cannot enter cells and it builds up in the bloodstream, the blood becomes hypertonic, in the body tries to get rid of the excess glucose by increasing urine output(polyuria). In the option to increase excretion of urine, the body increased thirst(polydipsia) to replace lost fluid. 0-1% insulin production When there is glucose, when there is salt, follow water Polyphagia, polydipsia, polyuria, weight loss Activity # 1 If you are a nurse caring for a patient with Type 1 Diabetes , what will you prepare? Make a 24-hour meal plan for Dominic an 18 year old college student who was recently diagnosed of DM type 1. His weight is 132 lbs and 5’8 ft in height. Answer the ff questions a. What is Dominic’s BMI? b. How will you classify Dominic in terms of BMI status? c. What are the factors that you consider in making the meal plan for Dominic? Treatment Everyone we type one diabetes requires exogenous insulin to maintain normal blood glucose level and to survive. Optimal insulin management can we realized only by evaluating blood glucose monitoring records,adjusting food and exercise activities, in proposing insulin adjustment. I. Types of Insulin Types of insulin are classified into three groups according to duration of their action: rapid or short acting, intermediate acting, and long acting. Insulin table Patterns of insulin administration vary with type ofbaby dies and desired glycemic control. The three basic types of insulin administration regimen are: a. Conventional or standard insulin therapy - it is composed of a constant dose of intermediate acting insulin combined with short or rapid acting insulin or a mixed-dose love in spleen. Insulins may be mixed by the patient or purchase premixed (30 units of 70/30 insulin). administration of insulin and food intake must be synchronized to avoidhypoglycemia. b. Flexible or intensive insulin therapy - it is composed of multiple daily injection offshore rapid acting insulin before meals, as well as intermediate acting insulin once or twice daily. This approach allows insulin to be adjusted to correspond with food intake, imitating endogenous insulin secretion in a person without diabetes. insulin doses can also be adjusted to treat hyperglycemia, inconsistent carbohydrate intake, or modification in usual physical activity. Insulin regimen must be integrated with the patient's lifestyle. Individuals who use intensive therapy should know the basic insulin doses for both insulins they use. c. Continuous subcutaneous insulin infusion - it is a form of intensive therapy. Rapid or short acting insulin is pumped continuouslyin micro amountthrough a subcutaneous catheter and is monitored 24 hours a day. Boluses of rapid or short acting insulins are given before meals. Activity # 2 1. What are the types of Insulin? Please place your answer using the template below. Types of Sample Appearance Onset Peak Duration Insulin under each type II. Exercise Exercise like insulin lowers blood glucose level, in maintaining normal lipid levels, and increases circulation. For most individuals, consistent and individualized exercise helps reduce the therapeutic dose of insulin. People with type one diabetes who do not have complications and are in good blood glucose control can perform all levels of exercise, include recreational sports, and competitive sports. To do so safely, the patient must possess the ability to collect self-monitored blood glucose data and then use this data to adjust the therapeutic regimen (insulin and medical nutrition therapy). General guidelines for regulating the glycemic response to exercise a. Metabolic control before exercise > Avoid exercise in fasting glucose level are greater than or equal to 250 milligrams/dL and ketosis is if glucose level present or if glucose levels are greater than 300 mg/dL, regardless of whether ketoses is present. Ingest added carbohydrates if glucose levels are less than m100 g/dL. Patients with type one diabetes should not perform exercise at the time insulin is at its peak. ideally, they should exercise when blood glucose levels are between 100 and 200 mg/dL or about 30 to 60 minutes after meals. they should also avoid exercising when blood glucose is greater than 250 mg/dL or when ketones are present in the urine. >Blood glucose monitoring before and after exercise -identify when changes in insulin or food intake are necessary. learn the blood glucose response to different exercise conditions. >Food intake - consume added carbohydrates as needed to avoid hypoglycemia. Carbohydrate based foods should be readily available during and after exercise. Glucose control can be compromised if proper adjustments are not made in food intake or insulin administration. TYPE 2 DIABETES MELLITUS Primary metabolic problem in type 2 diabetes is insulin resistance - it is the failure of cells to respond to insulin produced by the body, or defects in insulin secretion. Due to abused lifestyle Risk factors a. b. c. d. e. f. High risk ethnicity calcatians are prone to DM health disparities obesity taking of certain drugs Gestational Diabetes genetics People with type 2 diabetes have gradual onset of polyuria and polydipsia, and are easily fatigued , and have frequent infections(especially of the urinary track) .some of the first symptoms that cause individuals to seek medical attention are complications associated with diabetes such as stroke and heart attack. Upper body obesity, defined as awaist to hip ratio greater than .8 for women and .95 to 1 for men, is a risk factor for diabetes, heart disease, and hypertension. Management of diabetes Controlled blood glucose levels are the cornerstone of diabetes management. Improved control is correlated with sustained reduced rates of Retinopathy, nephropathy, and neuropathy. Hyperglycemia leads to long lasting epigenetic modification, with changes in chromatin structures and altered gene expression. Glycemic control can be monitored by measurement of glycosylated hemoglobin, or hemoglobin A1c along with self-monitoring of blood glucose.Glycosylated hemoglobin is formed through an irreversible process, as red blood cells circulate in the bloodstream, hemoglobin combines with glucose, forming glycosylated hemoglobin. The amount of glycosylated hemoglobin formed depends on the amount of glucose in the bloodstream circulation during the red blood cells’ 120-day lifespan. The more glucose and RBC was exposed to, the higher the value. This value is not affected by short-term factors such as food intake, exercise, or stress, so the blood sample can be drawn at any time. Selfmonitoring and charting are useful in evaluating glycemic control, physical activity, and effectiveness of the meal plan in meeting the goal. Self-monitoring of blood glucose can be performed in the individuals home with blood glucose meter, which can be purchased at pharmacies. Self-monitoring of blood glucose is recommended three or more Times Daily for nearly all individuals with type one diabetes and for pregnant women taking insulin, individuals with type 2 diabetes who take insulin usually needs to perform self-monitoring of blood glucose more often than those not taking it. Blood glucose levels are often regulated as follows : Before meals : 70 to 130 mg/dL two hours after meals :less than 180 mg/dL bedtime : 90 to 150 mg/dl Hypoglycemia Hypoglycemia (low blood sugar, less than 70 mg/dL) usually results from taking too much insulin, skipping meals, or engaging in too much exercise without a concomitant increase in food intake. Hypoglycemia can occur during exercise that lasts longer than one hour 224 hours after unusually strenuous or prolonged exercise. onset is sudden, and the complication can be fatal if left untreated. Hypoglycemia can occur when plasma insulin (or oral hypoglycemic agents) levels peak or during the night while the patient sleeps (fasting). Blood glucose levels should be monitored regularly consuming 15 to 20 grams off a fast-acting carbohydrate in the initial treatment for Hypoglycemia. If blood sugar levels 15 minutes after treatment are still low breed with another 15 to 20 grams of fast-acting carbohydrates and recheck the blood sugar level in 15 minutes. Repeat these steps until the blood sugar is greater than 70 mg/dL. Diabetic ketoacidosis Diabetic ketoacidosis( DKA) occurs when the body cannot produce enough insulin and breaks down fat for fuel, producing high levels of acid. Severe DKA , is defined by a pH less than 7.15, a form of metabolic acidosis; hyperglycemia causes osmotic diuresis, dehydration, and lactic acidosis.Lower pH stimulates the respiratory center and produces deep , rapid respiration known as Kussmaul’srespiration. Large amount of ketone bodies in the body produce a fruity, acetone odor to the breath. If this condition is not recognized and treated promptly , the acidosis and dehydration may lead to loss of consciousness and possibly, and death. Patients w/ DM 1 keto (ketone or fat content in the body, as source of energy of the patient). No insulin, no sugar. Faster in onset, easier to fix, young people signs and symptoms: Dry skin high sugar 250-500mg/dL Ketones in the urine and in the bloodstream, Kussmauls respiration is a rapid breathing fruity odor Abdominal pain Acidosis metabolic acidosis, pH less than 7.35 (normal 7.357.45) Cause: Sepsis Sickness of stomach (viral) Stress (caused by surgery) Skipping insulin injection No specific diet as long as controlled Hyperglycemic high sugar hyperosmolar high oncotic pressure nonketotic syndrome Hyper glycemic hyperosmolar nonketotic syndrome( HHNS), like DKA, is a life threatening emergency caused by a relative or actual insulin deficiency resulting in severe hyperglycemia. Most often it is triggered by trauma or infection that increases the body's demand for insulin. If hyperglycemia is left untreated, so serum becomes hyperosmolar. Osmotic diuresis causes significant loss of electrolytes via urine. The mortality rate for HHNS is 10% to 25%. Type 2 diabetes, very few insulin, slow onset, hard fix, older, serious illness and infection. Signs and symptoms: Highest sugar over 600mg/dL High fluid loss Head changes, neurological manifestation such as confusion.No abdominal pain, no ketones, no acid, no kussmauls breathing. Slow onset and severe cellular dehydration 400mL per hour, stable potassium level. Food and nutrition therapies Nutrition therapy is an essential element of glycemic control and diabetes self-management education(DSME). individualize nutrition therapy is required to achieve treatment goals. The basis for nutrition therapy and the ability self-management educationInvolves a comprehensive nutrition assessment, a self-care treatment plan, and the client's health status, learning ability, readiness to change, and current lifestyle. The key is to tailor the mealplanning approach to individual needs.Individuals using intensive insulin therapy have flexibility inwhen and what they eat, whereas people using conventional insulin therapy must be consistent with timing of each meals and amounts of food consumed. Recommendation for total fat, saturated fat, cholesterol, fiber, vitamins, and mineralindeed are the same for individuals with diabetes as those in general population. Carbohydrate recommendations are based on the individual’sEating habits, blood glucose, and lipid goals. Protein intake can range from 15% to 20% of daily kcal from animal and vegetable protein sources. If diabetes is well controlled, blood glucose levels are not affected by moderate alcohol use. Nutrition therapy is an integral component of diabetes management and DSME. It involves conducting a nutrition assessment clever way to patient’s food intake, metabolic status, lifestyle, and willingness to make changes, goal setting, nutrition education, individualized counseling, and monitoring and evaluation. To enhance compliance, the plan should be individualized. Nutrition therapy should consider a person's usual eating habits and other lifestyle factors. Maintaining consistency within an eating pattern, rather than following an arbitrary eating style , will result in lower glycosylated hemoglobin level. other related nutrient issues include use of nutritive and nonnutritive sweeteners. Food exchange lists provides a good estimation of nutrient and calorie content for planning meals. It is useful to measure the size of each serving demand to eyeball correct serving sizes. Role of the nurse The role of the nurse in caring for the nutritional needs of patient with diabetes varies according to the settings and the age of the client. The general approach is to become aware of and help assess the patient's knowledge of, understanding, and adherence to the prescribed diet. When adherence is faulty, the nurse needs to offer information and support. Knowledge deficit can be remedied by the nurse or the dietitian do you lack motivation is harder to handle. When a trusting relationship exists between the nurse and patient, discussions about motivation and concerns can take place. The nurse may then influence the patient be more concerned about his or hurt long term welfare. Activity number 3 1. What is the difference between Diabetic Ketoacidosis from Hyper glycemic hyperosmolar nonketotic syndrome? Discuss in terms of a. Etiology b. Signs and symptoms c. Nursing Management d. Medical management Special considerations During periods of illness blood glucose values may become elevated, and diabetes control may worsen. These changes are caused by an increase in hepatic production of glucose that has been stimulated by infection, illness, injury or stress. Under such conditions, please hyperglycemia increases insulin requirement. Although illness increased the needs for insulin, decreased appetite and food intake are common. Gastroparesis Approximately 20% to 30% off individuals with diabetes experience delayed gastric emptying (gastro paresis). This condition can manifest as heartburn, nausea, abdominal pain, vomiting, early satiety,and weight loss. Gastro paresis occurs from vagal autonomic neuropathy and occurs more often in type one diabetes. Dietary treatment involves careful monitoring of intake. Carbohydrates should be replaced with food of soft or liquid consistency. Takes small meals may be better tolerated than three large meals. A low-fat diet may be useful to prevent the delay in gastric emptying. With metoclopramide (reglan) to increase gastric contractions and relax the phyloric sphincter, the patient may experience dry mouth, fluids can be increased, and food moistened with broth. Insulin should be matched with meals the regulate delayed absorption and glucose changes. If Constipation or diarrhea occurs, fiber intake is altered according to patient needs. Formation of an indigestible solid mass can occur after eating oranges, coconut, Greenpeace, apples, fix, potato skin, and Brussels sprout. Eating disorders Eating disorder in type one diabetes are somewhat common. Once insulin therapy is initiated, weight gain occurs. Disordered eating from body image problems has been nicknamed bulimia and anorexia nervosa. What is dangerous is insulin omission keep weight under control. Warning signs of potential eating disorder includes changes in usual eating pattern, unexplained elevation ofglycosylated Hemoglobin A1 Excessive exerciseand frequent episodes of DKA, which may be fatal. Diabetes management for pregnant women The risk of fetal of normality and mortality is increase in the presence of hyperglycemia,so every effort should be made to control blood glucose levels. Diabetes has reached epidemic proportion in indigenous populations around the globe, and there is an urgent need to improve the health of pregnant women with diabetes through timely and appropriate strategies.Changes that they please during pregnancy greatly affect diabetes control and insulin use. Some hormones and enzymes produced by the placenta are antagonistic to insulin, thus reducing its effectiveness. Maternal insulin does not cross the placenta, but glucose does. The fetal pancreas increases insulin production if blood glucose level gets too high. The increased production of insulin causes macrosomia, The large for gestational age infant(L G A). LGA newborns may experience respiratory difficulties, hypocalcemia, hypoglycemia, hypokalemia,or jaundice. Individualization of nutrition therapy is contingent on maternal weight and height. Adequate calories and nutrients must meet the needs of the pregnancy and should be consistent with established maternal blood glucose goals. Blood glucose monitoring provides information About the impact of food on blood glucose levels. Blood glucose goals during pregnancy are as follows: a. fasting less than or equal to 95 mg/dL b. one hour postprandial: less than or equal to 140 mg/dL c. two hours postprandial: less than or equal to 120 mg/d There are no unique weight gain recommendation for women with diabetes. Desired weight gain goals are based on pregnancy BMI. No caloric adjustments are needed for the first trimester, during the 2nd trimester and 3rd trimesters, An increased energy intake of approximately 100 to 300 kcal/day Is recommended. High quality protein should be increased by 10 g/day and can be supplied easily with one or two extra glasses of low fat or skim milk or one to two ounces of meat or meat substitute. As with any pregnancy 400 microgram per day of folic acid is recommended for prevention of neural tube defects and other congenital abnormalities. Energy restriction must be cautious . A minimum of 1700 the 1800 kcal/day off carefully selected food has been found to prevent ketoacidosis. Gestational diabetes Develops in about 5 to 6% of all pregnancies. It occurs more often among American Indian, African American, and Hispanic Latina American women. Women in whom gestational diabetes develops Are often obese but weight reduction should not be attempted during the pregnancy. Good glucose control is usually accomplished by individualization of intake And grabbing of weight gain. Often insulin may be prescribed to reduce the risk of fetal macrosomia, neonatal hyperglycemia, and perinatal mortality.Treatment options includes oral anti diabetes and pharmacologic therapy. Glucose level usually revert to normal after delivery, but there is an increased risk for later development of type 2 diabetes. Activity #4 case study : Joey 15 years old me to diabetes clinic center for the first time. Diagnosed with type one diabetes mellitus two years ago. He is the only one in his family who has diabetes . He lives with his parents, a younger brother and a younger sister. being his nurse you will create a successful plan of care. Assessment Subjective my blood sugar has been bouncing all over the place the nurse suggested that I come to diabetes clinic if I want to control my blood sugar and feel better I have been thinking about getting an insulin pump. I hate checking my blood sugar and giving myself shots. I take four shots a day now. I'd like a pump that will measure my blood sugar Ann give me insulin automatically. I want to be the same as my friends. They can eat whatever they want whenever they want and I don't want to be different objective blood glucose level is 180 mg/dL Joey injects lantus insulin at bedtime and Humalog insulin immediately before meals he has not seen a dietitian since he was first diagnosed and does not follow any special meal plan hemoglobin A1c value was 8% questions 1. create one priority nursing care plan for Joey with rationalization 2. create a 24 hour meal plan for Joey
