Nutrition and Diabetes Mellitus PDF

+ Nutrition and Diabetes Mellitus Nutrition-related diseases Dr. Ola Anabtawi + Introduction  Diabetes (dye-uh-beet-eez) - From the Greek word meaning “a siphon” - Refers to the excessive urine formation associated with the disease  Mellitu...

+ Nutrition and Diabetes Mellitus Nutrition-related diseases Dr. Ola Anabtawi + Introduction  Diabetes (dye-uh-beet-eez) - From the Greek word meaning “a siphon” - Refers to the excessive urine formation associated with the disease  Mellitus (MELL-ih-tus or mell-eye-tus) - “honey” or sweet (sugar) - Refers to the sweet smell and taste of the urine + Characteristics Group of metabolic disorders of glucose regulation and utilization Elevated blood glucose concentrations (hyperglycemia) Disordered insulin metabolism + Blood glucose regulation (70-100 mg/dl) + + Insulin role To "unlock" the cells of the body so that glucose carried by the blood can be used for energy. + Overview  Insulin secretions may be impaired  Cells that are normally responsive to insulin may become resistant to its effects  Or both Unrestrained glucose production in the liver and abnormal responses to insulin by muscle, adipose, and liver cells + Hyperglycemia ––marked elevation in blood glucose levels Long-term damage correlated with failure of eyes, kidneys, nerves, heart, blood vessels - + Nutrient flow during fasting + Overview Type 1 diabetes: the less common type of diabetes in which the person produces no insulin at all Type 2 diabetes: the more common type of diabetes that develops gradually and is associated with obesity and insulin resistance Insulin resistance: the condition in which the cells fail to respond to insulin as they do in healthy people Impaired glucose tolerance: inability to maintain normal blood glucose levels without excessive insulin production + Pre-diabetics What are the differences in occurring (Age, mechanism) ? Honey moon period (type-1 diabetes) + + + Signs and symptoms Frequent urination (polyuria) Dehydration, dry mouth Increased thirst (polydipsia) Blurred vision Weight loss Increased hunger (polyphagia) Fatigue + picture + 73 million adults (20-79) are living with diabetes in the IDF MENA Region in 2021. This figure is estimated to increase to 95 million by 2030 and 136 million by 2045. 27 million adults living with diabetes in the IDF MENA Region are undiagnosed - 38% of the total number of adults living with diabetes in the region. 48 million adults in the IDF MENA Region are living with Impaired Glucose Tolerance (IGT), Prevalence which places them at increased risk of developing type 2 diabetes. This number is estimated to increase to 63 million by 2030 and 81 million by 2045. Diabetes is responsible for 796,000 deaths in the IDF MENA Region in 2021. USD 33 billion was spent on healthcare for people with diabetes in 2021. 1 in 7 live births in the IDF MENA Region are affected by hyperglycaemia in pregnancy. + Diagnosis + + C-peptide test Once secreted, both insulin and C-peptide are routed through the liver. In the liver, insulin Proinsulin is the prohormone binds to its receptors and initiates glucose precursor to insulin made in uptake, inhibits gluconeogenesis, the beta cells of the islets of glycogenolysis, and ketogenesis and is Langerhans degraded within 5 to 10 minutes. C-peptide, on the other hand, has limited degradation in the liver and is degraded by the kidney + picture + Type-1 Diabetes Childhood or adolescents Classic symptoms: - frequent urination - Weight loss - Increased thirst - Ketoacidosis may occur may due to excessive production of ketone bodies + Type-2 Diabetes Insulin resistance Reduced insulin sensitivity To compensate: Pancreas secretes larger amount of insulin (hyperinsulinemia) Insulin hyperglycemia impaired insulin secretion insulin + Gestational Diabetes 7% of women Increased risk: - Family history - Obesity - Have given birth to infants weighing more than 9 pounds (almost 4 kg) Routinely tested between 24- 28 weeks of gestation + Prevalence IDF USA- CDC The prevalence of high blood glucose (hyperglycaemia) in pregnancy increases rapidly with age and is highest in women over the age of 45. In 20191: There were an estimated 223 million women (20-79 years) living with diabetes. This number is projected to increase to 343 million by 2045. The vast majority of cases of hyperglycaemia in pregnancy were in low- and middle-income countries, where access to maternal care is often limited. + Other causes of diabetes  Consequence of genetic defects - Cystic fibrosis  Diseases that can damage the pancreas - Pancreatitis  Hormonal imbalance  Drug or chemical toxicity + Complications + Acute complications Ketoacidosis (DM 1) Hyperosmolar hyperglycemic state (DM2) Hypoglycemia – low blood glucose + Ketoacidosis Quick development Can be fetal BGL >300 mg/dl Symptoms: excessive thirst, frequent urination, nausea and vomiting, abdominal pain, shortness of breath, fruity-scented breath, confusion + + Ketoacidosis Treatment fluids, electrolytes - Sodium, potassium and chloride Insulin Hypoglycemia/ hypokalemia + Hypoglycemia Most often occurs in DM1 but accounts for 3- 4% of deaths in insulin-treated patients Symptoms: - Hunger - Sweating - Shakiness - Heart palpitations - Slurred speech - Confusion + Hypoglycemia- Mental confusion If occurs during sleep – patients may be unaware of its presence Prolonged hypoglycemia – may result in permanent brain damage + Hypoglycemia treatment Mild - 15 g CHO, recheck, add 15 g if needed Severe - inject glucagon or glucose + Chronic complications Retinopathy Nephropathy Neuropathy CVD Why? + Effects of AGEs: Advanced Glycated End-products Complications typically affect the large blood vessels – macrovascular complication Arterioles and capillaries – microvascular complications Nervous system - neuropathy + Macrovascualr complications Accelerate atherosclerosis development – affects coronary arteries and arteries in limbs DM2 patients usually have multiple cardiovascular risk factors – hypertension, abnormal blood lipids, obesity (excess fat cells) + Higher risk of thrombosis Impaired blood flow to limbs – claudication – pain upon walking – leads to development of foot ulcers – can lead to gangrene – requiring amputations + Microvascular complications Diabetic retinopathy - Damage to small vessels in the retina – impair vision – cause blindness in DM 1 & DM 2 - Intensive management substantially reduces risk. + Diabetic nephropathy - Damage to small vessels (glomeruli) of the kidneys – in later stages of DM 1 & DM 2. - Intensive management substantially reduces risk. + Diabetic Neuropathy - Nerve degeneration – occurs in 50% of DM cases. - Extent of nerve damage dependent upon severity and duration of hyperglycemia. + Treatment + Type 1: - Insulin therapy Type 2: - Diet therapy - Exercise - Oral medications or insulin + Gestational diabetes: + Goal Maintain blood glucose Prevent or reduce the complications Control blood pressure Maintain healthy lipid concentrations, reduce the risk of:  Developing CVD  Peripheral vascular diseases Manage weight + Evaluating treatment  Self-monitored glucose testing- SMBG - Type 1: 3 or more times/day  Long-term - Glycated hemoglobin (HbA1c) - Measures glycemic control in past 2-3 months - 4-6% for non-diabetic persons - < 7% for DM patients +  Routine blood pressure checks  Lipid screening: - Annually  Urinary protein screening +  Physical exam - Screen for signs of retinopathy, neuropathy, and foot problems  Ketone testing  DM1  Gestational diabetes + + + Body weight and diabetes Type 1 - Newly diagnosed are thin/normal weight - Usually gain weight with insulin therapy Type 2 - Newly diagnosed usually overweight - Worsens insulin resistance - Weight loss + Type-1 Scenario Scenario Scenario Scenario Scenario 1 (%) 2 3 4 5 Carbs 50 47 45 55 60 Protein 15 18 20 20 20 Fat 35 35 35 25 20 Type-2 Scenario Scenario Scenario Scenario Scenario 1 (%)- 2 3- low fat 4 5 Low- diet carb Carbs 25 55 65 55 60 Protein 25 20 25 25 20 Fat 50 25 10 20 20 + + Nutrient recommendation Carbohydrates: - 50 to 55%total kcalories - High fiber, whole grain  Fiber - Same as general population  Sugar - not restricted - Minimize foods & drink with added sugar - Fructose ––may adversely affect blood lipid levels + Fat  Same as general population - Saturated fat ––limited < 10% of kcalories - Cholesterol intake < 300 mg daily - unless have increased LDLs  If LDL cholesterol level elevated - Saturated fat 7% of kcalories - Cholesterol < 200 mg daily + Protein - 15-10% of kcalories Micronutrients - Same as general population + + Glycemic response How food processed or prepared Fiber content Other foods included in the meal Individual tolerances + Glycemic Index Blood glucose response in people with type 2 diabetes to meals containing white bread or spaghetti + + Meal planning strategies 1. Carbohydrate Counting - Person given a daily carbohydrate allowance - Divided into pattern of meals & snack matching insulin dose 2. Exchange list - Sorts foods according to their proportions of CHO, fat, & protein - Each food has similar macronutrient & energy content + + + + Insulin types Classified based on: - Onset of action - Peak time - Duration of action Basal Insulin/ Bolus insulin Dosage typically based on body weight, adjusted based on blood glucose levels + + + + Insulin Delivery Injection with syringes, Insulin pens Insulin pumps + + Insulin therapy and hypoglycemia Most common complication Need immediate intake of glucose or CHO food 15-20 grams Relieves in 10- 20 minutes + Options of 15g CHO 2-3 glucose tablets 1 tbs sugar 15 small jelly ½ cup unsweetened grape juice ½ cup canned orange juice + Oral antidiabetic management Improves insulin secretion Reduces liver glucose production Improves glucose use by tissues Delays CHO absorption + + Other types Modifier of insulin action: Amylin analogue (pramlintide) Incretins and agents that prolong incretin action - GLP-1 (exenatide) - DPP-4 inhibitor Medications increase incretin  increase insulin  decrease blood glucose (example: medication to stimulate GLP-1 secretion) DPP-4 enzyme  decrease incretin  decrease insulin increase blood glucose DPP-4 inhibitor  stop DPP-4 action  no effect incretin --> increase insulin + + Selected drugs that alter glucose control Contribute to Hypoglycemia: - Some diuretics - Niacin (LDL/ HDL treatments)– depends Contribute to hyperglycemia: - Hypertension treatments - Some Diuretics - Beta-blockers - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6954773/ + Physical activity Improves insulin sensitivity Improves lipid levels Lowers blood pressure Promotes weight loss + + + + Physical activity and insulin dose Doses need to be reduced Check blood sugar before & after If blood glucose below 100 mg/dL, consume carbohydrate prior to exercising Proper footwear Proper hydration