Diabetes Mellitus: Types and Diagnosis

Dietary Management of Diabetes

• Diabetes mellitus is a metabolic disorder of multiple etiologies
• Diabetes is characterized by chronic hyperglycemia
• Diabetes involves disturbances of carbohydrate, fat, and protein metabolism
• Diabetes results from defects in insulin secretion, insulin action, or both

Types of Diabetes

• Type 1 Diabetes Mellitus
• Type 2 Diabetes Mellitus
• Gestational Diabetes
• Other types of diabetes include:
  • LADA (Latent Autoimmune Diabetes in Adults)
  • MODY (maturity-onset diabetes of youth)
  • Secondary Diabetes Mellitus

Diagnosis of Diabetes

• Common methods for diagnosing diabetes involve measuring fasting plasma glucose level (FPG) in the early morning
• For patients with fasting plasma glucose level (FPG):
  • Below 100 mg/dL is considered normal
  • Between 100 and 125 mg/dL indicates pre-diabetes
  • Above 125 mg/dL is considered diabetic

Type 1 vs Type 2 Diabetes

• Type 1 diabetes is insulin dependent
• Type 1 accounts for 5-10% of diabetic patients
• Type 1 mainly affects infants and children
• Type 1 results from an autoimmune destruction of the β-cells of the pancreas
• Type 1 requires insulin treatment to survive
• Type 2 diabetes is non-insulin dependent
• Type 2 accounts for 90-95% of diabetic patients
• Type 2 mainly affects adults
• Obesity causes insulin resistance in Type 2 diabetes
• Autoimmune destruction of β-cells does not occur in Type 2
• Type 2 does not require insulin treatment

Targeted Groups for Diabetes Screening

• Adults with a BMI of 25 kg/m² or more with one or more of the following risk factors should be screened:
  • Sedentary lifestyle
  • Family history of diabetes
  • History of gestational diabetes or delivering a baby that weighed more than 9 pounds
  • Blood pressure greater than 140/90 mmHg or taking antihypertensive medication
  • High-density lipoprotein (HDL) < 35 mg/dL and/or a triglyceride level > 150 mg/dL
  • Other conditions related to insulin resistance

Management of Diabetes

• Diet and exercise is the cornerstone
• Oral hypoglycemic therapy
• Insulin therapy

Goals of Nutritional Management of Diabetes Mellitus

• Achieve and maintain normal blood glucose, optimal blood lipid levels, and normal blood pressure
• Prevent, delay, or treat nutrition-related complications
• Provide adequate kilocalories for achieving normal body weight
• Provide optimal nutrition for maximizing health, growth, development, pregnancy, and lactation

Ideal Diet Plan

• Balanced diet with carbs, fats, and proteins
• High nutrient-dense foods
• Low energy-dense foods
• Less processed foods
• Variety of unprocessed foods
• High antioxidant foods
• High fiber content

Expected Outcomes of Medical Nutrition Therapy (MNT) in Diabetes:

• Decrease of 1% of A1C in patients with newly diagnosed Type 1 diabetes.
• Decrease of about 2% of A1C in persons with newly diagnosed Type 2 diabetes.
• Decrease of about 1% of A1C in persons with Type 2 diabetes of 4-year duration.
• Decrease LDL-C by 15-25 mg/dL in 3-6 months.

Diabetes Assessment Data: Diet History

• Usual caloric intake should be assessed
• Quality of the usual diet should be assessed
• Times, sizes, and contents of meals and snacks should be assessed
• Review food preferences
• Assess restaurant eating habits
• Determine who usually prepares meals
• Identify eating problems or intolerances
• Review the individual's beverage intake
• Note any supplements used

Diabetes Assessment Data: Daily Schedule

• Note the Time of waking
• Review usual meal and eating times
• Review work schedule or school hours
• Type, amount, and timing of exercise
• Review useal sleep habits

Medical Nutrition Therapy (MNT) in Type 1 Diabetes

• Insulin therapy should be integrated into an individual’s dietary and physical activity pattern
• Individuals using rapid-acting insulin by injection or an insulin pump should adjust the meal and snack insulin doses based on the carbohydrate content of the meals and snacks
• For individuals using fixed daily insulin doses, carbohydrate intake on a day-to-day basis should be kept consistent with respect to time and amount
• Insulin doses can be adjusted for planned exercise
• Extra carbohydrates may be needed for unplanned exercise

Medical Nutrition Therapy (MNT) Strategies in Type 2 Diabetes

• Implement lifestyle changes to reduce intakes of energy, saturated and trans fatty acids, cholesterol, and sodium.
• Increase physical activity to improve glycemia, dyslipidemia, and blood pressure.
• Plasma glucose monitoring can determine if adjustments to foods and meals will achieve blood glucose goals, or if medication needs to be combined with MNT.

Carbohydrates in Diabetes

• A dietary pattern including carbohydrates from fruits, vegetables, whole grains, legumes, and low-fat milk is encouraged for good health
• Monitoring carbohydrates via counting, exchange, or estimation remains a key strategy in achieving glycemic control

Carbohydrate and Diabetes Considerations

• Sucrose-containing foods can be substituted for other carbohydrates in the meal plan.
• If sucrose-containing foods are added to the meal plan, they can be covered with insulin or other glucose-lowering medications
• Care should be taken to avoid excess energy intake
• The use of glycemic index and load may give a modest additional benefit over that observed when total carbohydrates are considered alone

Glycemic Index Factors

• Glycemic index is influenced by factors such as:
  • Starch structure
  • Fiber content
  • Cooking methods
  • Degree of processing
  • Whether it is eaten in the context of a meal
  • Presence or absence of fat and protein

Sweeteners and Diabetes

• Sugar alcohols and non-nutritive sweeteners are safe when consumed within the daily intake levels established by the Food and Drug Administration (FDA)

Nutritive Sweeteners: Fructose

• Delivers 4 kcals/gram
• Has lower glycemic index than sucrose or starch
• Large amounts may negatively affect lipids
• There is no advantage to substituting it for sucrose
• Found naturally in foods such as fruits and vegetables

Protein and Diabetes

• Insufficient evidence suggests that usual protein intake (15-20% of energy) should be modified

• In individuals with Type 2 diabetes, ingested protein can increase insulin response without increasing plasma glucose concentrations

• Protein should not be used to treat acute or prevent nighttime hypoglycemia

• High-protein diets are not recommended as a weight loss method at this time.

• Long-term effects of protein intake >20% of calories on diabetes management and its complications are unknown

• While high-protein diets may produce short-term weight loss and improved glycemia, these benefits may not be maintained long term

• Long-term effects on kidney function in persons with diabetes are unknown

Dietary Fat Guidelines

• Saturated Fat: Less than 7% of total calories
• Cholesterol: Less than 200 mg/day in people with diabetes
• Minimize intake of trans-fatty acids
• Two or more servings of fish per week providing n-3 polyunsaturated fatty acids are recommended

Optimal Mix of Macronutrients

• The best mix of protein, CHO, and fat varies depending on individual circumstances
• Dietary Reference Intakes (DRIs) recommend that healthy adults consume 45-65% of energy from CHO, 20-35% from fat, and 10-35% from protein
• Total caloric intake must be appropriate for weight management

Micronutrients

• Vitamin/mineral needs of people with diabetes who are healthy appear to be adequately met by the RDAs
• Supplementation may be needed by:
  • Those on extreme weight-reducing diets
  • Strict vegetarians
  • The elderly
  • Pregnant or lactating women
  • Clients with malabsorption disorders
  • CHF (congestive heart failure) or MI (myocardial infarction)
• Chromium and magnesium are beneficial only if the client is deficient

Sodium Intake Recommendations

• There is an association between hypertension (HTN) and both types of diabetes mellitus (DM)
• The same sodium intake as the general population is recommended for otherwise healthy people with DM, less than 3000 mg/day
• For people with mild HTN and diabetes, sodium intake should be less than 2000 mg/day
• For people with more serious HTN or edematous clients with nephropathy, recommend 1500 mg/day or less

Goals of MNT for Diabetes in Children

• Maintain normal growth and development
• Evaluate using growth charts every 3-6 months
• Base nutrition prescription on the nutrition assessment
  • Re-evaluate every 3-6 months
• Base the meal planning approach on CHO counting

Medical Nutrition Therapy (MNT) for Type 2 Diabetes in Youth

• Cessation of excessive weight gain
• Promotion of normal growth and development
• Encourage healthy eating habits and increased activity for the whole family
• Address other health risk factors

MNT Essential Self-Management Skills

• Adjustments of CHO or insulin for exercise
• Grocery shopping guidelines
• Guidelines for eating out
• Snack choices
• Mealtime adjustments
• Use of sugar-containing foods and non-nutritive sweeteners
• Problem-solving tips for special occasions
• Travel schedule changes
• Work shifts if applicable

Meal Plan

• Estimate current energy, carbohydrate, protein, and fat intake
• Evaluate current meal pattern and schedule
• Adjust meal plan to promote treatment goals for energy, fat, and carbohydrate distribution
• Evaluate based on standard meal planning standards, such as the Food Guide Pyramid

Meal Plan: Patient on MNT Only

• Often start with 3-4 CHO servings per meal (includes fruits, starches, milk, sweets) for women
• Start with 4-5 CHO servings per meal (includes fruits, starches, milk, sweets) for men plus 1-2 for a snack if desired
• Evaluate the feasibility of the meal plan with the patient
• Trial the meal plan and evaluate blood glucose records
• Adjust the plan as necessary

Meal Plan: Oral Medications

• May do well with smaller, more frequent meals and snacks, especially if taking an insulin secretagogue
• Snack servings should be taken from the meal plan

Meal Plan: Insulin

• Can start with the meal plan and devise an insulin regimen to fit
• Many patients require a bedtime snack to prevent night-time hypoglycemia
• Patients who use morning intermediate-acting insulin (NPH) may require an afternoon snack
• Patients on rapid-acting insulin do not need a snack

Meal Planning: Carbohydrate Counting

• Focuses on CHO as the major driver of post-prandial blood glucose
• It can be used for intensive management or basic meal planning
• Most appropriate for Type 1 patients
• Must still address energy needs and the composition of overall diet
• Allows increased flexibility
• 1 carbohydrate serving = 15 grams
• Each rapid-acting insulin unit needs 10-15 gm CHO

Hypoglycemia

• Hypoglycemia is low blood glucose
• Hypoglycemia is a common side effect of insulin therapy
• Sometimes affects patients taking insulin secretagogues
• Hypoglycemia may be life-threatening

Hypoglycemia Treatment

• Glucose of 70 mg/dL or lower should be treated immediately
• A level of 60 to 80 mg/dL may require carbohydrate ingestion, deferral of exercise, or change in insulin dosage
• Treatment involves ingestion of glucose or carbohydrate-containing food, glucose is preferred
• Protein does not help with treatment or prevent the recurrence of hypoglycemia

Causes of Hypoglycemia

• Medication errors
• Excessive insulin or oral medications
• Improper timing of insulin in relation to food intake
• Intensive insulin therapy
• Inadequate food intake
• Omitted or inadequate meals or snacks
• Delayed meals or snacks
• Increased exercise or activity
• Unplanned activities
• Prolonged duration or increased intensity of exercise

Diabetic Ketoacidosis (DKA)

• DKA is caused by hyperglycemia

• DKA is life-threatening but reversible

• DKA involves severe disturbances in carbohydrate, protein, and fat metabolism

• DKA is caused by inadequate insulin for glucose utilization

• In DKA, the body uses fat for energy, forming ketones

• Acidosis results from increased production and decreased utilization of fatty acid metabolites

• Elevated blood glucose levels (≥250 mg/dL but usually <600 mg/dL).

• Presence of ketones in blood and urine.

• Polyuria (frequent urination), polydipsia (excessive thirst), hyperventilation, dehydration, fruity odor, and fatigue manifest.

• DKA may lead to coma and death

• DKA often occurs during acute illness (flu, colds, vomiting, and diarrhea).

DKA Treatment

• Supplemental insulin
• Fluid and electrolyte replacement Medical monitoring