dr. s. nishan silva (mbbs). diabetes- what is it? body is not producing or has lost sensitivity to...
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Diabetes- What is it?
• Body is not producing or has lost sensitivity to insulin.
• Insulin is a hormone that is needed to convert sugar, starches and other food into energy.
• Insulin is produced in the body by the pancreas.
Types of Diabetes
There are several types of diabetes:
• Type I - body does not produce any insulin.
• Type II- body is not making enough or is losing sensitivity to insulin made.
Types of Diabetes
• Secondary - a consequence from another disease. For example, pancreatitis or cystic fibrosis.
• Gestational Diabetes- diabetes during pregnancy.
• Impaired Glucose Tolerance- an intermediate between normal and diabetes.
Insulin from the Insulin from the pancreaspancreas
Vad happens to the carbohydrates from Vad happens to the carbohydrates from the food? the food?
- -- -
- -- -- -
Fat/muscle cellFat/muscle cell
Stored sugar in the Stored sugar in the liver (glycogen)liver (glycogen)
Carbohydrates Carbohydrates from foodfrom food
A healthy cellA healthy cell
InsulinInsulin
OO22 COCO22
WaterWaterEnergyEnergy
Urine test showsUrine test shows
Glucose Ketones Glucose Ketones
0 00 0
BloodBloodvesselvessel
CellCell
StarvationStarvation
(Insulin)(Insulin)
in liverin liver FattyFattyacidsacids
KetonesKetones
Urine test showsUrine test shows
Glucose Ketones Glucose Ketones
0 +0 +
BloodBloodvesselvessel
CellCell
Diabetes - lack of insulinDiabetes - lack of insulin
CellCell
in liverin liver FattyFattyacidsacids
KetonesKetones
Urine test showsUrine test shows
Glucose Ketones Glucose Ketones
+++ ++++++ +++
BloodBloodvesselvessel
Type I
• Usually diagnosed in children and young adults.
• Must take daily insulin shots to stay alive.
• Type I accounts for 5-10% of the population with diabetes.
Type II
• The most common form of the disease.• Approximately 50% of men and 70% of
women are obese at the time of diagnosis.• Nearing epidemic proportions, due to
increase # of older Americans, greater occurrence of obesity and sedentary lifestyles.
Gestational Diabetes
• Pregnant women have a higher insulin level.
• If woman has hyperglycemia, her blood glucose crosses the placenta but her insulin does not.
• This can cause a high birth weight for baby.
Pathology of Diabetes
Age
%Insulin resistance
Beta cell activity
Reduced beta cell activity
New Point of Diabetes
Causes for Beta cell exhaustion
1. Pancreatic damage
2. Pancreatic insufficiency
3. Other?
Pathology of Diabetes
Age
%Insulin resistance
Beta cell activity
Increased Insulin resistance
New Point of Diabetes
Causes for Insulin Resistance
1. Increased skin fat
2. Reduced muscle use of glucose
3. Other?
Pathology of Diabetes
Age
%Insulin resistance
Beta cell activity
Reduced beta cell activity
Increased Insulin resistance
New Point of Diabetes
Pathology of Gestational Diabetes
Age
%Insulin resistance
Beta cell activity
Point of Diabetes
Ges. Diabetes
Who’s at risk?
• Obesity
• First degree relative with diabetes
• Belongs to a high-risk ethnic group
• Was diagnosed with gestational diabetes or delivered a baby whose birth weight >9 lbs.
• Hypertension
Who’s at risk?
• HDL level<35 or triglycerides >250
• Found to have impaired glucose tolerance or impaired fasting on a previous test.
Treatment Goals for Type I
• Match insulin to food intake.
• Type I’s are encouraged to be precise and regular from day to day with food intake, insulin regimen, and activity.
Exercise and Type I’s
• Increases flexibility, muscular strength , and well being.
• Must monitor insulin and food intake to match exercise regimen.
• Increases insulin effectiveness and sensitivity in the body.
Treatment Goals for Type II
• Achieve normal or near-normal blood glucose levels.
• Provide adequate calories for reasonable body weight.
• Prevent, delay or treat nutrition related complications.
• Improve health through optimal nutrition.
Exercise and Type II
• Especially beneficial in type II diabetes.
• Promotes weight loss
• Increases insulin sensitivity.
• Must also be aware of medication and intake to prevent hypoglycemia.
Treatment of Diabetes
• Diet plays a major role.
• Carbohydrates are the component of food that causes an increase in blood sugar.
• Diabetics are encouraged to keep track of the amount of CHO they eat.
Nutrition
• Nutrition Therapy – The Most Fundamental Component of the Diabetes Treatment Plan
• Goals:– Near Normal Glucose Levels– Normal Blood Pressure– Normal Serum Lipid Levels– Reasonable Body Weight– Promotion of Overall Health
Nutrition Consult
• Conduct Initial Assessment of Nutritional Status• Diet History, Lifestyle, Eating Habit• Provide Patient Education Regarding
– Basic principles of diet therapy– Meal planning– Problem solving– Developing individualized meal plan– Emphasize one or two priorities– Minimize changes from the patient’s usual diet
Nutrition Therapy
• Provide Follow-up assessment of the meal plan to– Determine effectiveness in terms of glucose
and lipid control and weight loss– Make necessary changes based on weight
loss, activity level, or changes in medication– Provide ongoing patient education and
support
Methods of Carbohydrate Control
There are many new methods of controlling diabetes, these are still the two most common.
• Exchange Lists
• Carbohydrate counting- Very basic, allows a little more freedom and variety.
Blood Glucose Monitoring
• All diabetics must keep track of blood glucose levels.
• This is the only way to know if the treatment is effective.
• Gives the diabetic a good indication of what affects their blood sugar level.
• Must check at least 2 times a day and four times a day for at least 3 days a week.
Hemoglobin A1c
• A good indicator of blood glucose control.
• Gives a % that indicates control over the preceding 2-3 months.
• Performed 2 times a year.
• A hemoglobin of 6% indicates good control and level >8% indicates action is needed.
Nutrition Assessment
• Type of diabetes, any complications
• Blood sugar control• Past medical history• Anthropometrics- height,
weight, BMI, body composition
• Biochemical- labs• Medications, including
supplements
• Dietary 24 hour recall (meals, snacks, and beverages)
• Favorite foods• Food allergies• Eating patterns and
habits• Physical activity• Readiness to change• Attitude
Diabetes and Co-morbiditiesDiabetes and Co-morbiditiesScreening ParametersScreening Parameters
• Body weight assessmentBody weight assessment– BMIBMI– Waist circumferenceWaist circumference
• Blood Glucose – RBS, FBS, PPBSBlood Glucose – RBS, FBS, PPBS• Blood PressureBlood Pressure• HbA1cHbA1c• LipidsLipids• Compliance with nutrition planCompliance with nutrition plan• Other – Renal functions, ECG, USS Other – Renal functions, ECG, USS
abdomen ?abdomen ?
Definition : Glycemic IndexDefinition : Glycemic Index
0 0.5 1 1.5 2 2.5 0 0.5 1 1.5 2 2.5 Time (h)Time (h)
Evaluation of the incremental rise of blood glucose (area under curve) after ingestion of a food that contains 50g of carbohydrates, as a
percentage of the same amount of carbohydrate from a reference food (white bread or glucose)
and absorbed by the same person
44
66
88
Plasma glucose Plasma glucose (mmol/l)(mmol/l)
The glycaemic index is a ranking of foods from 0 to 100 based on their effect on blood glucose levels
High GI eg: White bread
Low GI eg: legumes
Time
Blo
od g
luco
se l
evel
Glycemic Index in ‘Simple English’
• The amount of glucose released into blood by a certain type of food with the same amount of carbohydrates found in 50grams of glucose. So it’s a rate/ a ratio a percentage.
• Making simpler:- “How quickly does a certain type of food release glucose in to blood”
Glycemic Index (GI)Glycemic Index (GI)
• This is what matters! Food items with a higher glycemic index releases glucose faster into the blood. Food items with lower GI; vice versa.
• One gram of bread will release glucose faster than one gram of red rice (although the amount of glucose in both types of food might be the same; the speed of release is what matters!)
Definition : Glycemic IndexDefinition : Glycemic Index
Depends upon the rapidity of digestion and absorption of the carbohydrate (physical and chemical properties)
Depends on the fibre content of the food (More fibre in food means that type of food releases glucose slowly)
Definition : Glycemic IndexDefinition : Glycemic Index
Examples :-
Glycemic Index (Glucose) = 100%
Low Glycemic Index 55%
Medium glycemic index 56-69%
High glycemic index 70%
Effects of Low GI FoodsEffects of Low GI Foods
Satiety (You will feel ‘full’ quicker! But the Satiety (You will feel ‘full’ quicker! But the amount of glucose that goes in to the blood amount of glucose that goes in to the blood is limited.)is limited.)
Hunger (Because the food releases glucose Hunger (Because the food releases glucose slowly over a long time and stays in the slowly over a long time and stays in the stomach longer. So you don’t feel hungry stomach longer. So you don’t feel hungry often)often)
WeightWeight
Diseases reduces by low Glycemic Index Food
• Diabetes• Heart Disease• High levels of Cholesterol in blood• Cancers in Large bowel• Metabolic syndrome
(Diabetes/Obesity/High cholesterol and so many more)
• Alzheimer’s disease
What does this mean??
• The Glycemic index gives you a ROUGH idea of what to eat to prevent mainly Diabetes and a whole lot more.
• That doesn’t mean the amount is not important. For example; although red rice is ‘healthy’, you shouldn’t eat loads of it.
• Of course in addition to the Glycemic index you MUST consider the fat content in your food. Else you will prevent Diabetes but die of High blood pressure!!!!
Choose what you eat!!!
• There are several factors you have to consider before selecting what you eat.
• Glycemic index is just one of them ; a very important aspect recognized internationally and proven by many researches as the mainstay in diabetic diets.
• The concept of ‘food pyramid’ gives you just a glimps of what you might want to fill your plate with.
Dietary recommendations for diabetes
• Eat starchy foods regularly
• Eat more fruit and vegetables
• Reduce animal or saturated fat
• Cut down on sugar
• Reduce salt
Nutrition Intervention options Nutrition Intervention options for Diabetesfor Diabetes
• Reduce energy and fat intake Reduce energy and fat intake • Carbohydrate counting Carbohydrate counting • Simplified meal plansSimplified meal plans• Healthy food choicesHealthy food choices• Individualized meal planning strategiesIndividualized meal planning strategies• Exchange listsExchange lists• Insulin-to-carbohydrate ratiosInsulin-to-carbohydrate ratios• Physical activity and behavioral strategies Physical activity and behavioral strategies
Breakdown of Macronutrients
• Total carbohydrate: 45-65% of total calories
• Total Protein: 10-35% of total calories
• Total fat: 20-35% of total calories
% CHO, PRO, FAT
CHO
PROTEIN
FAT
Choose more high fibre foods
To help maintain blood glucose levels and cholesterol levels
• Fruit• Vegetables• Pulses• Oats
Helps to maintain a healthy gut
• Wholegrain cereals• Wholemeal bread• Wholewheat pasta• Brown rice
Reduce animal or saturated fat intake
• Use low fat milk• Use low fat spread
instead of butter• Use oil high in
unsaturated fat, eg olive oil, rapeseed oil
Choose the right sort of fat
SATURATED
• Full fat dairy produce (eg cheese, butter, full cream milk)
• Pies
• Biscuits
• Savoury snacks
• Lard
• Hard vegetable fat
MONO- UNSATURATED
• Olive oil
• Rapeseed oil
• Groundnut oil
POLY- UNSATURATED
• Sunflower oil (products)
• Oily fish
Reduce salt intake
• Cut down on added salt
• Use alternative seasonings
• Look out for reduced/low sodium foods, eg bread
• Avoid salt substitutes
Slide no 22 • MEDINFO/AIRE/182 Date of Preparation November 2004 •
4 injections per day 3 short + 1 intermediate acting
(basal bolus)
6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5
Breakfast Lunch Evening Meal Sleep
time
Insu
lin in
bl
ood
Outcome Measures for Outcome Measures for Nutrition InterventionsNutrition Interventions
• Maintain blood glucose levels (80-130)Maintain blood glucose levels (80-130)
• HbA1c (HbA1c (≤ 7%)≤ 7%)
• Achieve recommended blood lipid levels Achieve recommended blood lipid levels
• Optimize blood pressure (120/80)Optimize blood pressure (120/80)
• Maintain BMI Maintain BMI
• Weight loss, if obese (10% weight loss Weight loss, if obese (10% weight loss from initial)from initial)
Types of exercise
• Walking
• Biking and stationary cycling
• Lap swimming and water aerobics
• Weight lifting
• At least 3-4 times a week, 30-40 minutes per session, 50 to 70% of maximum oxygen uptake
Each Person With Diabetes is Different!
• Every person with diabetes should receive medical nutrition therapy based on his/her medical needs
• Your dietitian may suggest very specific goals for your weight, diet, and exercise depending on your health status
Modern treatment of childhood diabetesModern treatment of childhood diabetes
Traditional approachTraditional approach
-- Insulin, diet, and exerciseInsulin, diet, and exercise
Diabetes treatment todayDiabetes treatment today- Insulin, love and careInsulin, love and care
””It is no fun having diabetes - but you must be It is no fun having diabetes - but you must be able to have fun even if you have diabetes”able to have fun even if you have diabetes”
It is our job to adjust the diet to the child, not the It is our job to adjust the diet to the child, not the other way aroundother way around
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