Dr. S. Nishan Silva

(MBBS)

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.

Pathophysiology

• Genes

• Obesity

• Sedentary Lifestyle

• Aging

Pathology of Diabetes

Age

%Insulin resistance

Beta cell activity

Point of Diabetes

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 ?

The Glycemic The Glycemic IndexIndex

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%

Foods and their Glycemic Index valuesFoods and their Glycemic Index values

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.

The Plate Method

http://www.tops.org/images/plate.gif

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

Eat starchy foods regularly

• Bread• Potatoes• Rice• Pasta• Cereals• Plantain• Chapatis

Eat more fruit and vegetables

• Fresh

• Frozen

• Tinned

• Dried

• Juice

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

Use less fat in cooking

• Grill

• Dry-roast

• Microwave

• Steam

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

Cut down on sugary foods

• Not a sugar free diet

• Cut out sweets

• Cut out sugary drinks

Choose low sugar products

• Use diet or low calorie, sugar free drinks

Intense sweeteners

• Tablet

• Liquid

• Granulated

Reduce salt intake

• Cut down on added salt

• Use alternative seasonings

• Look out for reduced/low sodium foods, eg bread

• Avoid salt substitutes

Eat regular meals based on carbohydrate:

Breakfast

Lunch or snack meal

Main meal

Drink alcohol in moderation

That’s

2 units a day for women

3 units a day for men

Portion Control

http://www.snacksense.com/files/u1/portions_v4.jpg

Insulin regimens

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