Diabetes Mellitus & Metabolic Syndrome PDF

11/14/24 1 Diabetes Mellitus & Metabolic Syndrome ALVYN KLEIN A. MANA-AY, MPH, MSc, RND Associate Professor, HE-Nutrition & Dietetics Department College of Education, Silliman University 2 1...

11/14/24 1 Diabetes Mellitus & Metabolic Syndrome ALVYN KLEIN A. MANA-AY, MPH, MSc, RND Associate Professor, HE-Nutrition & Dietetics Department College of Education, Silliman University 2 1  11/14/24 Outline: Introduction Symptoms and Diagnosis of DM Types of Diabetes and Complications Hypoglycemia Treatment and Nutrition Therapy Recommendations DM and Pregnancy Metabolic Syndrome 3 https://www.youtube.com/watch?v=-B-RVybvffU&t=603s 4 2  11/14/24 Diabetes Mellitus Metabolic disorders characterized by elevated blood glucose concentrations and disordered insulin management Causes Unable to produce sufficient insulin Unable to use insulin effectively Results in hyperglycemia 5 Symptoms of Diabetes § Frequent urination (polyuria) § Dehydration, dry mouth § Excessive thirst (polydipsia) § Weight loss § Excessive hunger (polyphagia) § Blurred vision § Increased infections § Fatigue 6 3  11/14/24 7 Diagnosis of Diabetes Based primarily on plasma glucose levels Glucose tolerance test 75-gram glucose load followed by plasma glucose level measurements at prescribed intervals Overt symptoms of hyperglycemia Subsequent tests should verify 8 4  11/14/24 Diagnosis of Diabetes (cont’d.) Criteria for diagnosis Random plasma glucose concentration ≥200 mg/dL Plasma glucose concentration ≥126 mg/dL after 8-hour fast Plasma glucose concentration >200 mg/dL 2 hours after 75-gram glucose load 9 Prediabetes Blood glucose levels between normal and diabetic Fasting level: 100-125 mg/dL Two hours after glucose load: 140-199 mg/dL Individual at risk for developing diabetes and cardiovascular diseases Indicates metabolic defect that could lead to type 2 diabetes 10 5  11/14/24 Types of Diabetes Type 1 Diabetes Autoimmune destruction of pancreatic beta cells Insulin must be supplied by injection Environmental toxins or infections likely triggers Usually develops during childhood or adolescence Symptoms appear abruptly or gradually 11 Type 2 Diabetes Most prevalent form of disease Often asymptomatic Primary defect is insulin resistance Reduced sensitivity to insulin in muscle, adipose, and liver cells Pancreas secretes larger amounts of insulin to compensate, resulting in hyperinsulinemia Unable to compensate for diminished effect in cells Obesity increases risk 12 6  11/14/24 Features of Type 1 and Type 2 Diabetes Feature Type 1 Diabetes Type 2 Diabetes Prevalence in diabetic 5-10 percent of cases 90-95 percent of cases population Age of onset 40 yearsa Associated conditions Autoimmune diseases, viral Obesity, aging, inactivity, inherited infection, inherited factors factors Major defect Destruction of pancreatic beta cells; Insulin resistance; insulin deficiency insulin deficiency relative to needs Insulin secretion Little or none Varies; may be normal, increased, or decreased Requirement for insulin therapy All cases Some cases Former names Juvenile-onset diabetes Insulin- Adult-onset diabetes Noninsulin- dependent diabetes dependent diabetes A Incidence of type 2 diabetes is increasing in children and adolescents; in more than 90% of these cases, it is associated with overweight or obesity and a family history of type 2 diabetes. 13 Type 2 Diabetes in Children and Adolescents Most cases diagnosed in adults over 45 years Still rare in children but increasing in prevalence Overweight children or those with family history at increased risk May go undetected unless screened with high-risk groups Type 1 and type 2 diabetes difficult to distinguish in children 14 7  11/14/24 15 Acute Complications of Diabetes Mellitus, Part 1 Diabetic ketoacidosis in type 1 diabetes Excess production of ketone bodies due to breakdown of triglycerides and protein, releasing fatty acids into blood Acidosis results in lowered blood pH (250 mg/dL Other symptoms Dehydration Acetone breath Decreased blood pressure Altered mental status Fatigue, lethargy, nausea and vomiting 17 Acute Complications of Diabetes Mellitus, Part 3 Hyperosmolar hyperglycemic syndrome in type 2 diabetes Condition of severe hyperglycemia and dehydration Onset is one week or longer Symptoms High blood glucose (levels in excess of 600 mg/dL) Neurological abnormalities Patient unable to recognize thirst or replace fluids adequately 18 9  11/14/24 Hypoglycemia Reduced blood sugar from inappropriate management of disease Excess amounts of insulin or antidiabetic drugs Prolonged exercise Skipped or delayed meals Inadequate food intake Consuming alcohol without food Occurs most often in type 1 diabetes 19 Symptoms of Hypoglycemia Hunger Sweating Shakiness Weakness Dizziness Heart palpitations Slurred speech Confusion 20 10  11/14/24 Chronic Complications of Diabetes Macrovascular complications Accelerated development of atherosclerosis in the coronary arteries and those supplying the limbs Cardiovascular diseases account for majority of deaths in diabetics Type 2 diabetes associated with multiple risk factors for CAD Pain while walking Foot ulcers, which can lead to gangrene 21 Diabetic Foot Ulcer 22 11  11/14/24 Microvascular Complications Progressive damage to capillaries in the retina Can lead to visual impairments and blindness Neuropathy Damage to capillaries in the kidneys Prevents adequate blood filtration Kidney failure often develops Symptoms include pain in the legs and feet, and GI disturbances 23 Treatment of Diabetes Mellitus Diabetes is chronic, progressive disease Requires lifelong treatment Management involves meal planning, timing of medications, and physical exercise Primary goal: maintain blood glucose level in desirable range Control blood pressure and manage weight Certified Diabetes Educator provides knowledge and skills for treatment 24 12  11/14/24 Comparison of Conventional and Intensive Therapies for Type 1 Diabetes Empty Cell Conventional Therapy Intensive Therapy Blood glucose Monitored daily Monitored at least three times daily monitoring Insulin therapyb One or two daily injections; no daily Three or more daily injections or use of an adjustments external insulin pump; dosage adjusted according to the results of blood glucose monitoring and expected carbohydrate intake Advantages Fewer incidences of severe Delayed progression of retinopathy, hypoglycemia; less weight gain nephropathy, and neuropathy Disadvantages More rapid progression of Twofold to threefold increase in severe retinopathy, nephropathy, and hypoglycemia; weight gain; increased risk of neuropathy becoming overweight The therapies shown here were compared in the Diabetes Control and Complications Trial, which was conducted in patients with type 1 diabetes. b ln the Diabetes Control and Complications Trial, insulin therapy was conducted using various mixtures of short- acting, intermediate-acting, and long-acting insulins. Since the study, a variety of other insulin therapies have been developed (including rapid-acting insulin and long-acting insulin analogs), allowing for treatments associated with less risk of hypoglycemia. 25 Evaluating Diabetes Treatment Largely evaluated by monitoring glycemic status Self-monitoring of blood glucose Provides feedback for adjustment of food intake, medications, physical activity Helpful in prevention of hypoglycemia Useful in both type 1 and type 2 diabetes Frequency of monitoring depends on type of diabetes and specific needs of patient Long-term glycemic control Measuring glycated hemoglobin (HbA1c) 26 13  11/14/24 Monitoring for Long-Term Complications Blood pressure Lipid screening Urine protein checks Physical screening exams Retinopathy Neuropathy Foot problems 27 Monitoring for Long-Term Complications (cont’d.) Ketone testing Checks for development of ketoacidosis In presence of symptoms Increased risk of ketoacidosis Acute illness Stress Pregnancy 28 14  11/14/24 Nutrition Therapy: Dietary Recommendations Benefits of appropriate nutrition therapy Improve glycemic control Slow progression of complications Consider personal preference and lifestyle habits in planning Modified to accommodate growth, lifestyle changes, aging, and complications 29 Macronutrient Intakes Total carbohydrate intake Greatest influence on blood glucose levels after meal Recommendation based on metabolic needs, medication, and preference Whole grains, legumes, fruits and vegetables good sources 30 15  11/14/24 Macronutrient Intakes (cont’d.) Glycemic index (GI) Ranking carbohydrate foods based on glycemic effect Clinical studies mixed on effects of low GI diets Minimally processed foods frequently recommended 31 Sugars Moderate consumption does not affect glycemic control Recommendations similar to general population Count sugars as part of daily carbohydrate allowance Sugar alcohols and artificial sweeteners can be used as sugar substitute 32 16  11/14/24 Fiber and Fat Fiber Recommendations similar to those of general population Dietary fat Emphasizing monounsaturated fats may benefit glycemic control and CVD risk 33 Other Dietary Guidelines Protein guidelines similar to those for general population Study results mixed on benefit of high-protein diet Use alcohol in moderation and consume with food Micronutrients Vitamin and mineral supplements not recommended unless deficiencies develop 34 17  11/14/24 Nutrition Therapy: Meal-Planning Strategies Control carbohydrate intake and portion sizes Coordinate insulin injections with meals Adjust dosages to carbohydrate intake 35 Nutrition Therapy: Meal-Planning Strategies (cont’d.) Carbohydrate counting Simple approach Daily allowance based on individual energy and nutrient needs Consistent carbohydrate intake needed to match medication or insulin regimen 36 18  11/14/24 Food Lists Individuals choose foods with specified portions from a list Foods grouped according to properties Items on a list have similar carbohydrate, fat, and protein Less flexible than carbohydrate counting No advantages for glycemic control 37 Sample Carbohydrate Distribution for a 2000-kCalorie Diet Meals Carbohydrate Allowance: Grams Carbohydrate Allowance: Portions a Breakfast 60 4 Lunch 60 4 Afternoon snack 30 2 Dinner 75 5 Evening snack 30 2 Totals 255 g 17 Note: The carbohydrate allowance in this example is approximately 50% of total kcalories. a1 portion = 15 g carbohydrate = 1 portion of starchy food, milk, or fruit. 38 19  11/14/24 Translating Carbohydrate Portions into a Day’s Meals Meals Carbohydrate Portions Breakfast: Carbohydrate goal 4 portions or 60 g Breakfast: ¾ c unsweetened, ready-to-eat cereal 1 Breakfast: ½ c low-fat milk ½ Breakfast: 1 scrambled egg - Breakfast: 6 oz orange juice 1½ Breakfast: Coffee (without milk or sugar) - Lunch: Carbohydrate goal 4 portions or 60 g Lunch: 1 tuna salad sandwich (includes 2 slices whole- 2 grain bread, mayonnaise) Lunch: 6 oz yogurt (plain) with ¾ c blueberries and 2 artificial sweetener Lunch: Diet cola - Afternoon snack: Carbohydrate goal 2 potions or 30 g Afternoon snack: 2 sandwich cookies 1 Afternoon snack: 1 c low-fat milk 1 Dinner: Carbohydrate goal 5 portions or 75 g Dinner: 4 oz grilled streak - Dinner: 1 small baked potato (with margarine or 1 butter) Dinner: corn on cob, 1 large ear 2 Dinner: ½ c steamed collard greens a and 1 c sliced, 1 raw tomatoes Three servings of nonstarchy vegetables are equivalent to 1 carbohydrate portion. Dinner: ½ c ice cream 1 Evening snack: Carbohydrate goal 2 portions or 30 g Evening snack: 1 small apple 1 Evening snack: 1 oz granola bar 1 39 Insulin Therapy Insulin preparations Differences Onset of action Timing of peak action Duration of effects Classifications Rapid-acting Short-acting Intermediate-acting Long-acting 40 20  11/14/24 Insulin Therapy (cont’d.) Insulin delivery Usually administered by subcutaneous injection Individual syringes Disposable or reusable pens Insulin pumps Insulin is protein Would be digested if ingested orally 41 Insulin Preparations Form of Insulin Common Preparations Onset of Action Peak Action Duration of Action Rapid acting Lispro (Humalog) 5 to 15 minutes 60 to 90 minutes 3 to 5 hours Aspart (Novolog) Glulisine (Apidra) Short acting Regular 30 minutes 2 to 3 hours 5 to 8 hours Intermediate NPH 2 to 4 hours 6 to 10 hours 10 to 16 hours acting Long acting Glargine (Lantus) 1 to 2 hours Steady effects 24 hours Detemir (Levemir) Insulin mixtures NPH/regular (70:30) Variable; depends on Variable; depends on Variable; depends on (with sample NPL (modified lispro)/lispro formulation formulation formulation ratios) (50:50) 42 21  11/14/24 Effects of Insulin Preparations 43 Insulin Regimen: Type 1 Diabetes Best managed with intensive insulin therapy Multiple daily injections or use of insulin pump Factors that determine amount of insulin to inject prior to meal Pre-meal blood glucose level Carbohydrate content of meal Individual’s body weight and sensitivity to insulin 44 22  11/14/24 Insulin Injection (Left) and Insulin Pump (Right) 45 Insulin Regimen: Type 2 Diabetes About 30 percent of people with type 2 diabetes can benefit from insulin therapy Initially control with nutrition therapy, physical activity, and oral antidiabetic medications As pancreatic function worsens, may need insulin to achieve glycemic control Variety of regimens Insulin therapy only or combination of insulin with oral antidiabetic medications Dosages and timing adjusted with results of blood glucose self-monitoring 46 23  11/14/24 Insulin Therapy and Hypoglycemia Hypoglycemia often results from intensive insulin therapy Corrected with immediate intake of glucose or carbohydrate-containing food Patients should monitor blood glucose levels 47 Insulin Therapy and Hypoglycemia (cont’d.) Fasting hyperglycemia Develops in morning after overnight fast Usual cause is insufficient insulin at night Other causes Dawn phenomenon Rebound hyperglycemia 48 24  11/14/24 Antidiabetic Drugs Used to treat type 2 diabetes Regimens Use of single medication Combination of several medications Achieves more rapid and sustained glycemic control 49 Antidiabetic Drugs (cont’d.) Drug Category Common Examples Mode of Action Alpha-glucosidase inhibitors Acarbose (Precose) Miglitol Delay carbohydrate digestion and (Glyset) absorption Amylin analogs (injected) Pramlintide (Smylin) Suppress glucagon secretion, delay stomach emptying, increase satiety Biguanides Metformin (Glucophage) Inhibit liver glucose production, improve glucose utilization Bile acid sequestrants Colesevelam (Welchol) Unknown; may inhibit liver glucose production Dipeptidyl peptidase 4 (DPP-4) Saxagliptin (Onglyza) Sitagliptin Improve insulin secretion, suppress inhibitors (Januvia) glucagon secretion, delay stomach emptying Dopamine D2 receptor agonists Bromocriptine (Cycloset) Increase insulin sensitivity GLP-1 receptor agonists (injected) Exenatide (Byetta) Liraglutide Improve insulin secretion, suppress (Victoza) glucagon secretion, delay stomach emptying, increase satiety Meglitinides Nateglinide (Starlix) Repaglinide Stimulate insulin secretion by the (Prandin) pancreas Sulfonylureas Glipizide (Glucotrol) Glyburide Stimulate insulin secretion by the (Diabeta) pancreas Thiazolidinediones Pioglitazone (Actos) Increase insulin sensitivity Rosiglitazone (Avandia) 50 25  11/14/24 Physical Activity and Diabetes Management Central feature of diabetes management Substantially improves glycemic control Regular aerobic and resistance exercise can improve insulin sensitivity 51 Physical Activity and Diabetes Management (cont’d.) Need medical evaluation before starting exercise Mild to moderate exercise initially Proper hydration necessary before and during exercise 52 26  11/14/24 Maintaining Glycemic Control Careful adjustment of food intake and medication dosage to prevent hypoglycemia during activity Check glucose levels before and after activity Additional carbohydrates may be needed with prolonged activity Individuals with ketosis should avoid vigorous activity 53 Sick-Day Management Illness, injury, or infection cause hormonal changes that raise blood glucose levels Increased risk of diabetic ketoacidosis or hyperosmolar hyperglycemic syndrome Monitor blood glucose and ketone levels several times daily Adjust dosage of antidiabetic drugs or insulin as needed Ensure adequate fluid intake to prevent dehydration 54 27  11/14/24 Diabetes Management in Pregnancy Pregnancy increases insulin resistance and body’s need for insulin Increased health risks for both mother and fetus Uncontrolled diabetes increases rate of miscarriage, birth defects, and fetal death Respiratory and metabolic problems in newborn Large-birthweight infants (macrosomia) 55 Pregnancy in Type 1 or Type 2 Diabetes Glycemic control at conception and during first trimester reduces risks of birth defects and spontaneous abortion Women with type 1 diabetes require extensive insulin therapy during pregnancy Frequent adjustments may be necessary Type 2 diabetes may require switching from antidiabetic drugs to insulin therapy 56 28  11/14/24 Gestational Diabetes Risk factors Family history, obesity, specific ethnic groups, or previous delivery of baby over nine pounds Routine testing at 24-28 weeks gestation Modest caloric reduction may improve glycemic control Limit carbohydrate intake to 40-45 percent of total energy Regular meals and snacks throughout the day 57 Nutrition in Practice—The Metabolic Syndrome Cluster of metabolic abnormalities that increase risk of CVD and type 2 diabetes Diagnosed when three of the following disorders are present Hyperglycemia Obesity Elevated blood triglycerides Reduced HDL cholesterol levels Hypertension 23 to 34 percent of adults in U.S. meet criteria 58 29  11/14/24 The Metabolic Syndrome The disorders that characterize the metabolic syndrome are all independent risk factors for CVD Some medical experts question whether diagnosis of metabolic syndrome is useful Main benefit of grouping disorders may be to guide clinical management of interrelated problems 59 Causes of The Metabolic Syndrome Precise cause unknown Close relationship between abdominal obesity and insulin resistance may be partly responsible Adipose tissue breaks down triglycerides more rapidly, increasing fatty acid levels in the blood Enlarged adipose cells activate local macrophages to secrete cytokines that produce inflammation 60 30  11/14/24 Treatment for The Metabolic Syndrome Diet and lifestyle changes aim to correct abnormalities that increase CVD risk Weight loss and physical activity Can improve insulin resistance, blood pressure, and blood lipid levels Dietary recommendations Reduce intake of added sugars and refined grains Increase whole grains and foods high in fiber Restrict carbohydrate Reduce saturated fats, trans fats, and cholesterol 61 31