CLN 311 Clinical Nutrition Lecture 2-3 - PDF

CLN 311 Clinical Nutrition https://youtu.be/-B-RVybv U Lecture 2-3: Medical Nutrition Therapy for Diabetes Mellitus (DM) CLN 311 Clinical Nutrition What is Diabetes Mellitus (DM)? Diabetes mellitus is a gr...

CLN 311 Clinical Nutrition https://youtu.be/-B-RVybv U Lecture 2-3: Medical Nutrition Therapy for Diabetes Mellitus (DM) CLN 311 Clinical Nutrition What is Diabetes Mellitus (DM)? Diabetes mellitus is a group of diseases characterized by high blood glucose concentrations resulting from defects in insulin secretion, insulin action, or both. Insulin is a hormone produced by the beta-cells of the pancreas that is necessary for the use or storage of body fuels (carbohydrate, protein, and fat). 4 4 in Saudi Arabia: up to 24% Prevalence Naeem Z, Burden of Diabetes Mellitus in Saudi Arabia. International Journal of Health Sciences, Vol. 9, No. 3 (July-Sept 2015) CLN 311 Clinical Nutrition Categories of Glucose Intolerance 1. Prediabetes 2. Type 1 Diabetes Diabetes 9blood sugar 3. Type 2 Diabetes Insulin secretion 4. Gestational Diabetes Mellitus L J 5. Other types of Diabetes butnot to workaction CLNA311 ClinicalA1c hemoglobin Nutrition (HbA1c) test measures the amount of blood sugar (glucose) attached to hemoglobin. Screening and Diagnostic Criteria Normal Pre-diabetes Diabetes glycated haemoglobin to HBA1C (%) 5.7 – 6.4 - ≥ 6.5 e measures B.S ove the past 3 months Fasting Blood Sugar FBS (mg/dl) < 100 100-125 ≥126 nffyi. e.GE F Plasma Glucose (FPG)/(IFG) sizT Two-hour postprandial Him 2-H PP (mg/dl) Oral Glucose Tolerance Test < 140 140-199 ≥ 200 two a (2-H OGTT)/ (IGT) 140 199200 4 CLN 311 Clinical Nutrition Why A IN Screening and Diagnostic Criteria 63months Screening for diabetes should be considered in all adults who are overweight (BMI >25 kg/m2) and who whatare the have one or more additional risk factors for T2DM: be Metabolic syndrome High risk ü Physical inactivity 0 ü First-degree relative with diabetes Family History ethnicity OH ü Members of a high-risk population such as African Americans, Latino, Native American, Asian American. ü Women who have delivered a baby weighing more than44 082kg 9 lb or have been diagnosed with GDM O ü Hypertensive (blood pressure >140/90 mm Hg or taking medication for hypertension) low high Yoo q üfHigh-density lipoprotein (HDL) cholesterol level ,35 mg/dl (0.9 mmol/L) and/or a triglyceride level.250 mg/dl (2.82 mmol/L) Many women with PCOS have insulin ü Women with polycystic ovary syndrome (PCOS) resistance. Insulin levels build up in the body and may cause higher androgen levels. ü A1C >5.7%, IGT, or IFG on previous testing ü Other clinical condition associated with insulin resistance (e.g., severe obesity) O ü History of CVD CLN 311 Clinical Nutrition Age Screening and Diagnostic Criteria A Adults without these risk factors, testing should begin at age 45 years. If tests are normal, testing fastingBS should be done at 3-year intervals; A1C, FPG, or 2-h OGTT, can be used for testing. Youth who are overweight (BMI.85th percentile for age and sex, weight for height above the 85th percentile, or weight more than 120% of ideal for height) and have any two of the following risk factors should be screened: ü Family history of T2DM in first- or second-degree relative. ü Race/ethnicity (Native American, African American, Latino, Asian American, Pacific Islander) ü Signs of insulin resistance such as hypertension, dyslipidemia, PCOS, or small-for-gestational-age birth weight ü Maternal history of diabetes or GDM during the child’s gestation CLN 311 Clinical Nutrition Categories of Glucose Intolerance 1. Prediabetes 2. Type 1 Diabetes 3. Type 2 Diabetes 4. Gestational Diabetes Mellitus 5. Other types of Diabetes CLN 311 Clinical Nutrition IfG titis iz GT too no Iaa Prediabetes Individuals with a stage of impaired glucose homeostasis are referred to as having prediabetes, indicating their relatively high risk for the development of diabetes. People at risk may have IFG (fasting plasma glucose 100-125 mg/dL), IGT (2-hour post challenge glucose of (140 to 199 mg/dl) Clinical trials comparing lifestyle interventions to a control group have reported risk reduction for T2DM from lifestyle interventions ranging from 29% to 67% ( Youssef,2012) following diet plan 67% treated CLN 311 Clinical Nutrition Management of Prediabetes- Medical Management Fm judge Metformin is the only drug should be considered for DM prevention. It is the most effective in those with a BMI of at least 35 kg/m2 and who are under age 30. For other drugs, issues of cost, side effects, and lack of persistence of effect are of concern. Medical management must include lifestyle changes such as increase physical activity: For cardiovascular fitness and to reduce risk of T2DM, recommendations include moderate- intensity aerobic (150 min/week) or vigorous-intensity aerobic a minimum (90 min/week). For muscle-strengthening activities involving all major muscle groups two or more days per week are also recommended. Bariatric surgery is thought to reduce the incidence of T2DM (changes of neurohormonal and enterhormonal changes). More research is needed. CLN 311 Clinical Nutrition is diabetic people supposed to restrict/ reduce CHO r Management of Prediabetes Choose lower glycemic index No, we need it for insulin / energy/ maybe the patient IKE Medical Nutrition therapy for Prediabetes will have glycemia controlCHO healthy Noglasketonbodys Importance of food choices that facilitate moderate weight loss. plant-based foods Mediterranean-style eating pattern has been associated with a lower incidence of DM. It is characterized by: ↑ monosaturated fatty acid (olive oil), ↑ plant-based foods (veg, legumes, fruits), moderate amount of fish, ↓ intake red and processed meat, ↓ whole-fat dairy products. Pofalmofa f Whole grains and dietary fibers are associated with reduced risk of DM 461 Hwegg121W High consumption of sugar-sweetened beverages (soft drinks, fruit drinks, energy and vitamin watertype drinks containing sucrose, high-fructose corn syrup, and/ or fruit juice concentrates) is associated with the development of T2DM. Hara eating pattern high in saturated fatty acids and trans fatty acids is associated with increased markers of insulin resistance and risk for type 2 diabetes CLN 311 Clinical Nutrition Categories of Glucose Intolerance 1. Prediabetes wT iref His 2. Type 1 Diabetes Diabetes WE hypoglycemia 3. Type 2 Diabetes 4. Gestational Diabetes Mellitus 5. Other types of Diabetes CLN 311 Clinical Nutrition Lesscommenthen Type 1 Diabetes (T1DM) 1213 i T1DM accounts for 5% to 10% of all diagnosed cases of diabetes. Symptoms: The primary defect is pancreatic beta-cell destruction, leading to absolute insulin deficiency and r resulting in hyperglycemia, polyuria 3 (excessive urination), polydipsia 9 (excessive thirst), polyphagia S 6 (excessive hunger), weight loss, dehydration, 8 7 disturbance, and ketoacidosis. electrolyte The rate of beta-cell destruction is variable, proceeding rapidly in infants and children and slowly in others (mainly adults.) T1DM can develop at any age, lean, or overweight. Treatment: Insulin and diet therapy T1DM increase ‫فجأة‬ 44 T2DM increase gradually Wee fold CLN 311 Clinical Nutrition Type 1 Diabetes (T1DM) thecauseisunknown T1DM has two forms: immune-mediated and idiopathic. 1- Immune-mediated diabetes mellitus results from an autoimmune destruction of the beta- cells of the pancreas, the only cells in the body that make the hormone insulin. Increased frequency of immune-mediated disease such as Celiac disease and autoimmune thyroid disease with increased frequency in persons with T1DM. 2- Idiopathic T1DM refers to forms of the disease that have no known etiology. Children with T1DM should be screened for celiac disease and if present, gluten-free diet should be offered. CLN 311 Clinical Nutrition Type 1 Diabetes (T1DM)- Pathophysiology Markers of the immune destruction of the beta-cells include: islet cells autoantibodies autoantibodies to insulin ü autoantibodies to glutamic acid decarboxylase (GAD65) (a protein on the surface of the beta-cells), - One and usually more of these autoantibodies are present in 85% to 90% of individuals when fasting. ü Hyperglycemia and symptoms develop only after 90% of the secretory capacity of the beta-cell mass has been destroyed.  glu eatour glycogen glucose Theurine of Mkt ptwith Diabetes Insuline W havelglucosetketon Tketones CLN 311 Clinical Nutrition Effie o Hi a Type 1 Diabetes (T1DM)- Pathophysiology Diabetic Ketoacidosis (DKA) is the end result of abnormal metabolic abnormalities due to no insulin, resulting in: Hyperglycemia : BS > 250 mg/dl Ketosis: high serum ( >5 mEq/L)and urine ketone Acidosis: PH 40 Insulin required Yes Sometimes Cell response to insulin Normal Resistant Symptoms Relatively severe 1onset Relatively moderate Igradually Prevalence in Diabetic 90% Population 27 CLN 311 Clinical Nutrition How to distinguish T1DM and T2DM? marker If at diagnosis it is not clear whether T1DM or T2DM is present, C-peptide may be measured. When the pancreas produces insulin, it begins as a large molecule—proinsulin. This molecule splits into two equal-sized pieces: insulin and C-peptide. A person with T1DM has a low level of C-peptide, whereas a person with T2DM can have a normal or high level of C-peptide. As T2DM progresses, C-peptide also may be measured to see if endogenous insulin is still being produced by the pancreas. If it is not, exogenous insulin is needed. CLN 311 Clinical Nutrition Categories of Glucose Intolerance 1. Prediabetes 2. Type 1 Diabetes 3. Type 2 Diabetes 4. Gestational Diabetes Mellitus 5. Other types of Diabetes CLN 311 Clinical Nutrition Millarto T2DM Gestational Diabetes Mellitus FINE 634 occurs in about 7% of all pregnancies. After delivery, about 90% of all women with GDM become normoglycemic but are at increased risk of developing GDM in subsequent pregnancies. Women who have had GDM have a 35% to 60% chance of developing diabetes in the next 5 to 10 years. women with risk factors for diabetes should be screened for undiagnosed T2DM at the first prenatal visit, using standard diagnostic criteria. All women not previously known to have diabetes should be screened for GDM at 24 to 28 weeks of gestation. WHY THIS TIME? because of the increase in insulin-antagonist hormone levels and insulin resistance that normally occurs at this time. GDM does not cause congenital anomalies. GDM does not appear until later in pregnancy, the fetal organs were formed before hyperglycemia became a problem. CLN 311 Clinical Nutrition GDM IN Gestational Diabetes Mellitus GDM screening can be accomplished with either of two strategies: Forfast1pre factory 18 1- “One-step” 3-hr 75-g OGTT. A fasting glucose.92 mg/dl (5.1 mmol/L), a 1-hour 180 mg/dL (10 mmol/L), or a 2 hr 153 mg/dl (8.4 mmol/L) is diagnostic of GDM g “Two-step” approach with a 1-hr 50-g (nonfasting) screen followed by a 3-hr 100-g OGTT for those 2- with plasma glucose 140 mg/dl (10.0 mmol/L). The diagnosis of GDM is made when the plasma glucose level measured 2 hr after the test is 140 mg/dl (7.8 mmol/L). mmoyL X s mgld jg.SE CLN 311 Clinical Nutrition Gestational Diabetes Mellitus Why is important to control gestational diabetes? 1. Extra glucose from the mother crosses the fetal placenta and the fetus’ pancreas responds by releasing extra insulin to cope with the excess glucose. The excess glucose is converted to fat, which results in macrosomia. The fetus may become too large for a normal birth resulting in the need for cesarean delivery. 2. Neonatal hypoglycemia at birth. Maternal hyperglycemia have caused the fetus to produce extra insulin. ooh hyper ADMIT How to control is? Ø Diet and activity Ø if not helping pharmacologic therapy is needed (insulin, metformin, and glyburide) CLN 311 Clinical Nutrition Nutrition Care Process Nutrition Interventions for GDM Nutrition Therapy Interventions for women with Gestational DM MNT for GDM involves primarily a carbohydrate-controlled meal plan that promotes optimal nutrition for maternal and fetal health with adequate energy for appropriate gestational weight gain. Carbohydrates should be distributed throughout the day into three small-to-moderate size meals and two to four snacks. Weight gain during pregnancy for women with GDM should be similar to that of women without DM The ideal form of exercise is unknown, but a brisk walk after meals is often recommended. Monitoring records guide nutrition therapy are used to determine whether additional therapy is needed. Insulin, metformin therapy is added if glucose goals exceed target range. CLN 311 Clinical Nutrition Categories of Glucose Intolerance 1. Prediabetes 2. Type 1 Diabetes 3. Type 2 Diabetes 4. Gestational Diabetes Mellitus 5. Other types of Diabetes CLN 311 Clinical Nutrition Other types of diabetes Such types of diabetes may account for 1% to 5% of all diagnosed cases of diabetes This includes diabetes associated with: 1. specific genetic syndromes (such as maturity-onset diabetes of youth), 2. Genetic defects in insulin action 3. diseases of the exocrine pancreas (such as cystic fibrosis) Steriodslcoticesteriods 4. endocrinopathies, (such as acromegly or Cushing’s syndrome) awl 49,81 5. drug or chemical induced (such as in the treatment of HIV/AIDS or after organ transplantation) 6. infections, and other illnesses. CLN 311 Clinical Nutrition Management of Diabetes MNT, physical activity, monitoring, medications, and self-management education and support. Patients can assess day-to-day glycemic control by self-monitoring of blood glucose (SMBG) and measurement of urine or blood ketones. Longer-term glycemic control is assessed by A1C testing. Lipid levels and blood pressure also must be monitored For T1DM a flexible, individualized management program using the principles of intensive insulin therapy is essential. T2DM is a progressive disease. The “diet” doesn’t fail; the pancreas fails to secrete enough insulin to maintain adequate glucose control. As the disease progresses, MNT alone is not enough to keep A1C level at 7% or less. Therapy must intensify over time.  Recommendations for Glycemic Control for Diabetes Mellitus Normal Pre-diabetes Diabetes ≥ 6.5 HBA1C (%) 5.7 – 6.4 - Goal < 7.0 ≥126 FBS (mg/dl) < 100 100-125 Goal 80-130 2-H PP (mg/dl) ≥ 200 < 140 140-199 Goal < 180 aim to the Goal 37 CLN 311 Clinical Nutrition Management of Diabetes-Medical management CLN 311 Clinical Nutrition Management of Diabetes-Nutrition therapy Goals and Desired outcomes A unified focus of MNT for: T2DM is a reduced energy intake and T1DM carbohydrate counting is used to adjust bolus (premeal) insulin doses (insulin- to- carbohydrate ratios) CLN 311 Clinical Nutrition Management of Diabetes-Nutrition therapy Energy Balance and Weight management For children and adolescenets with T1DM: ü Provision of adequate calories for normal growth and development ü monitor growth by measuring height and weight every 3 months and recording it on growth charts For youth with T2DM: nutrition therapy goals include ceasing of excessive weight gain with normal linear growth. For adults with T1DM: attention to weight goals For adults with T2DM: Focus reduced energy intake and regular physical activity. ü Support for lifestyle changes is also essential. CLN 311 Clinical Nutrition H0 45 60 tobesafe50middle Management of Diabetes Pro 15 20 fat 330 Macronutrient percentage and Eating patterns There is not an ideal percentage of calories from carbohydrate, protein, and fat for all persons with diabetes Monitoring total grams of carbohydrates, whether by use of carbohydrate counting or experienced based estimation remains a key strategy in achieving glycemic control. Quantity and type of carbohydrate eaten influence blood glucose levels; however, the total amount of carbohydrate eaten is the primary predictor of glycemic response. CLN 311 Clinical Nutrition Management of Diabetes Macronutrient-Carbohydrate intake Carbohydrates types are sugars, starch, and fiber. Clinical studies do no justify the longtime belief that sucrose must be restricted. Carbohydrate counting is an Eating Plan method based on the principle that all types of carbohydrate (except fiber) are digested with the majority being absorbed into the bloodstream as molecules of glucose. carbohydrate serving is a portion of food containing 15 grams of carbohydrate. There are two main Eating Plans using carbohydrate counting: ü using insulin-to-carbohydrate ratios to adjust premeal insulin doses for variable carbohydrate intake (physiologic insulin regimens), or ü following a consistent carbohydrate Eating Plan when using fixed insulin regimens. Testing premeal and postmeal glucose levels is important for making adjustments in either food intake or medication to achieve glucose goals  fatPro d dGl u mad Glycemic index (GI) and Glycemic Load (GL) GI: A measure of how fast and how high a food will raise blood sugar (quality) Vegetables, fruit and low fat milk products have a low glycemic index Plan meals with grains and starches from the low and medium glycemic index list To reduce GI: Add protein, fat, fiber and/or acidity GL: Assess both the quality and the quantity of food sugar and how raise blood sugar 43 CLN 311 Clinical Nutrition Management of Diabetes Macronutrient-Glycemic index and load CLN 311 Clinical Nutrition Management of Diabetes Fibre and whole grains No evidence is found to recommend a higher fiber intake for diabetic patients ( same as nondiabetic 25-38g per day) Non-nutritive and hypocaloric sweeteners non-nutritive sweeteners currently approved for use by the FDA are: Saccharin, aspartame, neotame, acesulfame potassium, and sucralose There is no evidence that the amounts of sugar alcohols likely to be consumed will reduce glycemia or energy intake. CLN 311 Clinical Nutrition Management of Diabetes Protein intake The amount usually consumed by diabetics (15-20%) No evidence of a recommended protein intake is available. Therefore, goals should be individualized. Fat intake No evidence of a recommended fat intake is available. Therefore, goals should be individualized. The type of fat consumed is more important than total fat in terms of metabolic goals and influencing CVD risk. MUFA (monounsaturated fatty acid are associated with improved glycemic control and improved CVD risk factors in persons with T2DM Saturated fatty acids (SFA) < 10% of daily kcal. CLN 311 Clinical Nutrition Management of Diabetes Micronutrients and herbal supplements No clear evidence has been established for benefits from vitamin or mineral supplements in persons with diabetes (compared with the general population) who do not have underlying deficiencies. Herbal products are not standardized and vary in their content of active ingredients and have the potential to interact with and potentiate the effect of other medications. CLN 311 Clinical Nutrition Management of Diabetes Bariatric Surgery It is an effective weight loss treatment for severely obese patients with T2DM that may results in improvements in glycemia The ADA states it may be considered for adults with BMI of at least 35 kg/ m2 and T2DM, especially if the diabetes or associated comorbidities are difficult to control with lifestyle and pharmacologic therapy CLN 311 Clinical Nutrition hypoglycemia Physical Activity Exercise is a subset of physical activity: planned, structured, and repetitive bodily movement performed to improve or maintain one or more components of physical fitness. In persons with T1DM, the glycemic response to exercise varies, depending on overall diabetes control, plasma glucose and insulin levels at the start of exercise; timing, intensity, and duration of the exercise; previous food intake; and previous conditioning. In persons with T2DM, blood glucose control can improve with physical activity, largely because of decreased insulin resistance and increased insulin sensitivity, which results in increased peripheral use of glucose not only during but also after the activity. CLN 311 Clinical Nutrition Potential problems with exercise Hypoglycemia is a potential problem associated with exercise in persons taking insulin or insulin secretagogues. This is because of increased insulin sensitivity after exercise and the need to replete liver and muscle glycogen, which can take up to 24 to 30 hours. Hyperglycemia also can result from exercise of high intensity, likely because the effects of counterregulatory hormones. This is because hepatic glucose release exceeds the rise in glucose use. The elevated glucose levels also may extend into the post exercise state. CLN 311 Clinical Nutrition Exercise Guidelines Stay hydrated Modify insulin doses before or after, or ingest CHO after exercise. During moderate-intensity exercise, glucose uptake is increased by 8 to 13 g/hr; this is the basis for the recommendation to add 15 g carbohydrate for every 30 to 60 minutes of activity (depending on the intensity) over and above normal routines. Consuming carbohydrates immediately after exercise optimizes repletion of muscle and liver glycogen stores. CLN 311 Clinical Nutrition Exercise Recommendations perform at least 150 min/week of moderate-intensity aerobic physical activity spread over at least 3 days/week with no more than 2 consecutive days without physical activity. In the absence of contraindications, adults with T2DM should be encouraged to perform resistance exercise at least twice per week Children with diabetes or prediabetes should be encouraged to engage in at least 60 min/day of physical activity Routine screening pre-exercise is not recommended. High-risk patients should be encouraged to start with short periods of low-intensity exercise and increase the intensity and duration slowly. CLN 311 Clinical Nutrition Medications- oral agents The overall objective is to achieve and maintain glycemic control when lifestyle efforts alone have not achieved or maintained glycemic goals, oral agents maybe given. They increase the secretion of insulin by pancreatic beta cells, may improve binding between insulin and insulin receptors. CLN 311 Clinical Nutrition Medications-oral agents ü Metformin is the preferred initial pharmacologic agent for T2DM in addition to lifestyle counseling and support for weight loss and physical activity ü If A1C target goals are not reached after approximately 3 months, a second oral agent, a glucagon- like peptide 1 (GLP-1) receptor agent, or basal insulin is added. ü If A1C goals are not reached after another approximately 3 months, a three-drug intervention is implemented. ü If this combination therapy that includes a long-acting insulin does not achieve A1C goals, a more complex insulin therapy involving multiple daily doses, usually in combination with one or more noninsulin agents, is implemented. CLN 311 Clinical Nutrition Medications-Glucose lowering Medications for T2DM Class and Generic Name Principle Action Mean Decrease in A1C Weight loss Biguanide Decrease hepatic glucose 1.5-2 % Not associated with Metformin (Glucophage) production hypoglycemia Weight gain Sulfonylurea Stimulate insulin secretion from 1-2 % Potential to cause Glucotrol β-cells hypoglycemia Thiazolidinediones Improve peripheral insulin Weight gain 1-2 % TZDs sensitivity Edema Enhance glucose-dependent 1 Modest weight loss insulin secretion and suppress Cause Glucagon-like peptide 1 0.5-0.9 % post-prandial glucagon gastrointestinal secretion disturbance Stimulate insulin secretion from Glinides 1-2 % Weight gain β-cells CLN 311 Clinical Nutrition there's 4 type Medications-Insulin Exogenous insulin is required for T1DM and T2DM who cannot control blood glucose by other means Insulin has three characteristics: a toI work Ø onset of action: when they start g beek Ø Time of peak of action: when their effect on blood sugar is greatest Ø Duration of action: how long they work M ios XIN U-100 is the concentration of insulin used in the United States. This means it has 100 units of insulin per milliliter of fluid (100 units/ml). Cannot be administered orally. Injection for self-administration or IV administration. The health care team teaches people with T1DM to adjust their insulin doses to accommodate changes in eating patterns, physical activity, and blood glucose concentrations CLN 311 Clinical Nutrition amount Insulin Types type Rapid-Acting Insulins insulin analogs that differ from human insulin in To determine the accuracy of the dose, amino acid sequence but bind to insulin receptors. blood glucose checking is done before IT go fµ function in a manner similar to human insulin. meals and 2 hours after the start of the meals. Regular Insulin A short-acting insulin with a slower onset For best results the slow onset of regular of action and later activity peak insulin requires it to be taken 30 to 60 minutes before meals Intermediate-Acting cloudy in appearance. Insulin Long-Acting Insulins Insulin is absorbed from the subcutaneous tissue it must be given consistently at the same relatively quickly but then binds to albumin time. in the bloodstream, resulting in a prolonged action time of approximately 17 hours. Premixed Insulins Persons using premixed insulins must eat at specific times and be consistent in carbohydrate intake to prevent hypoglycemia. CLN 311 Clinical Nutrition glycogen H I Medications-Insulin Regimens Insulin regimens allow increased flexibility in the type and timing of meals. After individuals without diabetes eat, their plasma glucose and insulin concentrations increase rapidly, peak in 30 to 60 minutes, and return to basal concentrations within 2 to 3 hours. To mimic this, rapid-acting or short-acting insulin is given before meals, and this is referred to as bolus or mealtime insulin. Mealtime insulin doses are adjusted based on the amount of carbohydrate in the meal. Basal or background insulin dose is that amount of insulin required in the post absorptive state to restrain endogenous glucose output primarily from the liver. Basal insulin also limits lipolysis and excess flux of free fatty acids to the liver. Long-acting insulins are used for basal insulin CLN 311 Clinical Nutrition Medications-Insulin Regimens  wait Action of Insulin Types E y I l l l l l l l 60 CLN 311 Clinical Nutrition Insulin Regimens: Continuous Sustained Insulin Infusion (CSII) or Insulin Pump Therapy The insulin (usually a rapid-acting insulin) is pumped continuously by a mechanical device in micro amounts through a subcutaneous catheter. The pump delivers insulin in two ways: 1) in a steady, measured, and continuous dose (basal insulin) and 2) as a surge (bolus) dose before meals. Pump therapy requires a committed and motivated person who is willing to do a minimum of four blood glucose tests per day, understand increased risk of diabetic ketoacidosis, and learn the technical features of pump use such as the bolus calculator and “insulin-on-board” features. The individual also should be educated on MNT, including carbohydrate counting/estimation. Prandial boluses are dependent on carbohydrate intake, current blood glucose levels, and planned physical activity. Regularly scheduled outpatient follow-up with diabetes care is recommended Insulin Regimens: Continuous Sustained Insulin Infusion (CSII) or Insulin Pump Therapy CLN 311 Clinical Nutrition Monitoring Blood Glucose Self-monitoring of blood glucose(SMBG) Enables patient to make self-management decisions regarding diet, exercise, and medication Patients on multiple dose insulin or insulin pump therapy should do SMBG before meals, snacks, before exercise Important for detecting episodic hyperglycemia and hypoglycemia Patient training is crucial. CLN 311 Clinical Nutrition Monitoring Blood Glucose Continuous Glucose monitoring(CGM) CGM systems include a tiny glucose-sensing device called a sensor that is inserted under the skin in the subcutaneous fat tissue for several days at a time. The sensor measures glucose in interstitial fluid and transmits readings every 5 minutes to a monitor that is worn or carried externally. CGM devices provide information on current glucose level and on the trend and rate of change in glucose levels (i.e., whether the glucose level is rising or falling and how quickly). Other features include alerts for glucose highs and lows and the ability to download data and track trends over time. The ADA recommends that CGM in conjunction with intensive insulin regimens can be a useful tool to lower A1C selected adults (age of more than 25 years) with T1DM. CLN 311 Clinical Nutrition Monitoring Blood Glucose-A1C A1C tests should be done at least twice a year in persons who are meeting treatment goals and have stable glycemic control. They should be done quarterly in persons whose therapy has changed or who are not meeting glycemic goals. In persons without diabetes A1C values are 4% to 6%. CLN 311 Clinical Nutrition Monitoring Ketone, Lipid, Blood Pressure Urine or blood testing can be used to detect ketones. Testing for ketonuria or ketonemia should be performed regularly during periods of illness and when blood glucose levels consistently exceed 240 mg/dl (13.3 mmol/L). The presence of persistent, moderate, or large amounts of ketones, along with elevated blood glucose levels, requires insulin adjustments. Persons with T2DM rarely have ketosis; however, ketone testing should be done when the person is seriously ill. For most adults, lipids should be measured at least annually. Blood pressure should be measured at every routine diabetes visit. CLN 311 Clinical Nutrition Acute Complications of Diabetes Mellitus 1. Hypoglycemia Causes: main cause high insulin infusion with low carb intake and/or increase physical activity, skipped and/or delayed meals, inadequate food intake, vomiting, or severe diarrhea Severe hypoglycemia can lead to loss of consciousness, brain damage, and even death Treatment: glucose or simple sugar then rest in 10-15 minutes then repeat testing 67 CLN 311 Clinical Nutrition Acute Complications of Diabetes Mellitus 2. Hyperglycemia Hyperglycemia can lead to Diabetic Ketoacidosis Ketoacidosis is a life-threating condition; characterized by severe disturbance in carbohydrates, fat, and protein metabolism Ketoacidosis causes due to inadequate insulin for glucose use 68 CLN 311 Clinical Nutrition Chronic Complications of Diabetes Mellitus Micro-Vascular Nephropathy 3 6monthsEggs Retinopathy A Neuropathy Macro-Vascular Dyslipidemia Hypertension Chronic heart disease, peripheral vascular disease, cerebrovascular disease tend to occur at early age. It is more extensive and severe in people with T2DM 69 CLN 311 Clinical Nutrition Nutrition Care Process Nutrition Assessment Nutrition assessment is an ongoing process that involves not only initial data collection but also reassessment and analysis of patient data and needs. First, the RDN should assess food intake (focusing on carbohydrates) medication, metabolic control (glycemia, lipids, and blood pressure), anthropometric measurements, and physical activity as the basis for the implementation of the nutrition prescription, goals, and interventions. Second, the RDN should assess glycemic control and focus MNT to achieve and maintain blood glucose levels in the target range. Third, the RDN should assess the relative importance of weight management for persons with diabetes who are overweight or obese. CLN 311 Clinical Nutrition Nutrition Care Process Nutrition Interventions Two steps: planning the nutrition goals and implementing the actual interventions. 1. Planning involves prioritizing the nutrition diagnoses, conferring with the persons with diabetes and others, reviewing current nutrition practice guidelines for diabetes, setting goals, determining the nutrition prescription, and choosing specific intervention strategies. 2. Implementation is the action phase. In the food and nutrient delivery phase, an individualized eating plan is developed and specific nutrient recommendations are included. Nutrition education, nutrition counseling. CLN 311 Clinical Nutrition Nutrition Care Process Nutrition Interventions Nutrition Therapy Interventions for All People with Diabetes to promote and support a healthful eating pattern, emphasizing a variety of nutrient dense foods in appropriate portion sizes. monitoring carbohydrate intake It is important that individuals with diabetes know what foods contain carbohydrates—starchy vegetables, grains, fruit, milk and milk products, vegetables, and sweets; portion sizes; and how many servings they should select for meals (and if they desire, snacks). When choosing carbohydrate foods, nutrient-dense, high-fiber foods are recommended whenever possible instead of processed foods with added sodium, fat, and sugars. Sugar-sweetened beverages also should be avoided CLN 311 Clinical Nutrition Nutrition Care Process Nutrition Interventions Nutrition Therapy Interventions for T1DM and Insulin-requiring T2DM integrate an insulin regimen into the usual eating habits and physical activity schedule. individuals need to learn how to count carbohydrates or use another meal planning approach to quantify carbohydrate intake Insulin doses must be taken at consistent times every day. Consideration to total energy intake as weight gain may adversely affect glycemia, lipids, blood pressure, and general health; thus prevention of weight gain in adults is desirable For children: maintain normal growth and development Possible causes of poor weight gain and linear growth include poor glycemic control, inadequate insulin, and over restriction of calories CLN 311 Clinical Nutrition Nutrition Care Process Nutrition Interventions Nutrition Therapy Interventions for 2DM on MNT alone or with glucose lowering medications Adopt lifestyle interventions that improve metabolic abnormalities of glycemia, dyslipidemia, and hypertension. Reduced energy intake and increased energy expenditure through physical activity. The first step in food and meal planning is teaching which foods are sources of carbohydrate, appropriate portion sizes, and how many servings to select at meals (and snacks, if desired). Teaching that unsaturated fats should be substituted for foods high in saturated and trans fats For children: maintain normal and healthy body weight. Questions?