Chapter 27 Diabetes Melitus
Content
-Insulin dependent diabetes mellitus
-Non insulin dependent diabetes mellitus
-Most affected populations
-Complications of diabetes
1) Hyperglycemia, Dehydration, Glycosuria
2) Ketosis and coma in IDDM
3) Non-ketonic coma in NIDDM
4) Weight loss in IDDM
5) Weight gain in NIDDM
6) Hypoglycemia
7) Symptoms of hypoglycemia
-Functions of insulin
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Diabetes Is a chronic disease manifesting by elevated level of
glucose and altered energy metabolism. It may be caused by total absence of insulin
or by inefficient use of insulin by body cells.
Diabetes overview
It’s a major cause of blindness infections that lead to amputations, kidney failure
and birth defects .In addition to that people with diabetes are twice as likely to
develop cardiovascular complications.
Pancreas overview
Pancreas is en important organ necessary for metabolism of protein, fat as well as
carbohydrate. Regarding diabetes we are interested in the islets of Langerhans- the
endocrine cells of pancreas. These islets consists of several types of cells from which
we are particularly interested in beta cells secreting insulin and alpha cells secreting
glucagon
We generally recognize two types of diabetes
a) insulin dependent diabetes mellitus -IDDM
b) non insulin dependent diabetes mellitus- NIDDM
Insulin dependent diabetes mellitus
In this type of diabetes the pancreas is incapable of producing any insulin . It is
less common type and only about 5-10% of people are diagnosed with it. It is however
serious condition and ,people with this type -also known as type 1 diabetes require
insulin injection.
IDDM usually develops in individual under 20 years old -usually small children
but peaks also in patients with NIDDM who later develop IDDM. Current research believes
that IDDM can be cause by some kind of virus that triggers body attack on its pancreatic
tissue-beta cells and destroy it. We call this autoimmune disease.
Diabetes can however develop also as a secondary disease to pancreatitis, cystic
fibrosis as well as exposure to certain drugs and chemicals
Non insulin dependent diabetes mellitus
It is predominant type of diabetes, and includes some 90-95% of all diabetes cases.
Though the exact cause is unknown several predisposing factors such as obesity are
suspected.
The hallmarks of the disease are high blood glucose and insulin resistance.
Initially body cells become less responsive to insulin, and glucose level in the
blood will raise as well as levels of insulin called for, to cover the high level of
glucose. This eventually leads to hyperinsulinemia-high level of insulin. This chronic
demand for insulin eventually exhaust pancreas who literally burns out resulting in
IDDM . At this stage people will require insulin NIDDM usually develops
in people over the age of 40 and is frequently associated with obesity, physical
inactivity, abdominal fat. It is this high level of body fatness thatm lead to lower
sensitivity of body tissue to insulin.
People who are most likely to develop impaired glucose tolerance include
-Hispanics
-Native Americans
-African Americans
-obese people
- people over the age of 45
-people having relatives with diabetes
-women giving birth to babies weighing more than 9 pounds or have developed
hyperglycemia while being pregnant-gestational diabetes
Functions of insulin
-necessary for uptake of glucose
-increases also uptake of fatty acids
-stimulates protein, fat and glycogen synthesis
Complications of diabetes
Consequences are more acute in case of IDDM than NIDDM
1) Hyperglycemia, Dehydration, Glycosuria
Hyperglycemia resulting from insufficient insulin, or its ineffective
utilization leads to high concentrations of glucose in the blood. Body reacts by drawing
fluid from tissue into the blood-osmotic pressure. Blood volume thus increases and brings
blood to renal threshold. When blood glucose exceeds concentration of 180milligrams per
100 milliliters kidney cannot reabsorb glucose and excess glucose along with fluid and
electrolytes spills into urine. This will result in excessive urine production-POLYURIA
and excessive thirst-POLYDIPSIA.
2) Ketosis and coma in IDDM
In IDDM body cells don’t have steady access to energy fuel. Even though there is
dequate amount of glucose and a.a in the blood stream, cells are not getting it because
of lack off insulin. For that reason body start metabolizing fatty acids. Along with it
Ketone bodies are however produced. Resulting in Ketonemia-fruity odor in breath.
Presence of ketone in the blood lowers PH and leads to acidosis. When ketone bodies
appear in the urine we call it Ketonuria. In the urine , though we are also lousing
sodium and potassium along with ketones, and this worsens acidosis. When acidosis become
too severe , potential fatal coma may result.
3) Non-ketonic coma in NIDDM
In NIDDM people don’t suffer with ketosis and acidosis, but they may develop coma
from high levels of glucose and failure to drink sufficient amount of fluid. We call
this coma -Hyperglycemia non-ketonic coma.
4) Weight loss in IDDM
Despite large intake of food people with IDDM are very thin and generally are losing
weight if their diabetes is not properly controlled, because they are losing in the
urine their energy sources-glucose and ketone bodies and continue break down protein for
glucose production.
5) Weight gain in NIDDM
People in NIIDDM usually gain weight and remain obese because the excess of insulin
in the blood will convert the high level of glucose into fat and help it to be deposited
in the fat cells.
6) Hypoglycemia
It is usually consequence of inappropriate management of diabetes.
It can result from
-too much insulin
-strenuous physical activity
- skipped meal
- delayed meals
- vomiting or diarrhea
Symptoms of hypoglycemia
-hunger -headache
-sweating - shakiness
-nervousness - confusion
-disorientation - slurred speech
People on intensive therapy are more likely to develop hypoglycemia Untreated
hypoglycemia may lead to loss of consciousness, brain damage or even death
people with IDDM should wear bracelet with medical identification.
Chronic complications of diabetes
-Hyperglycemia destroys structure of blood vessels and nerves
- poor circulation leads to deterioration of nerves
- poor circulation along with high blood glucose also leads to infections
A) cardiovascular disease
More than 80% of people with diabetes die as a consequence of cardiovascular
diseases especially heart attack
b) Microangiopathies
Degeneration of small blood vessels leads to retinopathy-loss of vision and
nephropathy - loss of kidney function
c) Neuropathy
It is result of deteriorating of nerve tissue. After initial painful prickling
sensation in limbs and feet person may completely loose sensation in these areas leading
to undetected injuries. These injuries may lead to death of tissue due to gangrene and
thus necessitate in amputation of limb. For that reason people with neuropathy are
advised to pay close attention to their feet.
Neuropathy may also result in delayed gastric emptying. This may lead to premature
feeling of fulness and thus to energy imbalance, weight loss an poor glucose control.
Screening for diabetes
American Diabetes Association recommends that every person over the age 45 be tested
for diabetes every 3 years.
Most commonly high fasting blood glucose on two occasions suggest diabetes. Fasting
blood glucose higher than normal, but not high enough to confirm diabetes, indicates
impaired glucose tolerance People with impaired blood glucose are often advised to start
diet therapy for diabetes.
What is normal- interpretation of fasting blood glucose
normal= less than 110/100ml
impaired glucose tolerance 110-116mg/100ml
diabetes more than 116mg/100ml
Treatment of Insulin Dependent Diabetes Mellitus( IDDM)
The goal of therapy for person with diabetes is to maintain blood glucose within
normal range , achieve optimal lipid level, treat complications, control blood pressure
and support health and well being.
Diet in IDDM
Diet for person with diabetes is a regular healthy diet with the difference that
CHO intake must be consistent from day to day and meal to meal in the same amount or
insulin needs to be adjusted.
Energy
Diet is sufficient in energy to achieve or maintain healthy weight and to support
growth in pregnant women and children.
Carbohydrate
CHO directly affects blood glucose but it is not restricted in the diet of person
with diabetes. It is necessary for steady supply of glucose . The recommended amount
correlates with general recommendation for CHO intake, which is 45-55% of total Kcal.
It is however necessary to consume the same amount every day, and in every meal
approximately at the same time, to ease the task of coordinating insulin doses, and food
intake, and thus prevent hyperglycemia and hypoglycemia.
Diet should concentrate on whole grains such as whole wheat bread, pasta, legumes,
fruits and vegetables.
As far as concentrated sweets, they are not necessary strictly excluded from diet,
but instead we are looking at them in terms of CHO that is in limited amount part of
carbohydrate allowance with the same health consideration as in the diet of healthy
individual. These days health professionals agree that total CHO in the diet is of
greater concern than the type of CHO.Better choice is however, use of artificial
sweeteners containing less Kcal without the effect of raising blood glucose level.
Carbohydrate replacement for missed meal
In case of missed meal, person with IDDM needs to consume 15- 30grams of complex CHO
to prevent hypoglycemia. This can be also accomplished by drinking juice, flavored
gelatine,soft drink or frozen juice bar in case of poor appetite.
Protein
Protein should provide about 10-20% of total kcal need in the diet of diabetics.
Fat
Intake of fat should correlated with the Dietary Guidelines for Americans-30% of
total energy intake and not more than 10 % from saturated fat.
Sodium
People with diabetes frequently suffer with HBP and are generally advised to
restrict their NA intake to less than 3000mg per day.
Alcohol
Alcohol can cause hypoglycemia, because it prevents liver from generating glucose
through gluconeogenesis . For that reason person with IDDM is advised not to consume
more then two drinks a day.
Meal planing strategies
Traditionally exchange system is used to plan diet. This allows person to exchange
food items in any given group for one another.
Carbohydrate counting is another widely used strategy. It teaches client to focus
mainly on CHO containing foods. It involves eating consistent amount of CHO for any
given meal or snack.
How to plan diet for Diabetes using exchange list
1) determine reasonable weight for client and estimate how many kcal are necessary to
maintain or achieve this body wt.- calculate desirable body wt.
2) Perform diet history and estimate how many kcal is the client currently eating to
maintain his weight
3)Estimate how many kcal from clients diet come from protein, fat and carbohydrates and
compare that with dietary recommendation. 10-20% protein
45- 55% CHO
30% and less from fat
If changes to make diet more healthy are necessary adjust eating plan slowly to avoid
rapid unrealistic plans.
4) Translate Kcal from fat, prot. and CHO to grams
5) translate this diet prescription into meal plan. First divide grams of prot, fat and
CHO into exchanges from each food group. Try to make this flood plan as closely as
possible to meet clients real eating habits, but you may have to negotiate some changes
to get as close as possible to Daily food guide.(However this may be more appropriate
for clients after several years of initial exposure to new eating habits and becoming
more comfortable with all the new life stile changes.)
6) Translate the above numbers of exchanges into real food, fitting clients usual eating
pattern.Do not forget at this point to remind client to eat the same amount of
carbohydrate each day at the same time.
7) At the advanced stage, teach client how to make their own changes in their diet plan.
This means that they will be able to interchange for example foods from starch, fruit
and milk and other CHO list that contain similar amount of energy and CHO and can be
substituted for one another from time to time. But discourage them from regular
substitution of food since they may create nutrition deficiencies by excluding eg milk
and substituting it by only fruit group and vice versa.
Physical activity
Physical activity and blood glucose in IDDM
Blood glucose tend to fall in individual with mild hyperglycemia if they engage in
physical activity. They need to check their BG prior exercise and avoid vigorous
physical activity if their BG is too high-greater than 300Miligrams per 100ml.
Physical activity and food intake
Person with IDDM needs to eat before, during and after vigorous activity-especially
CHO. Generally it is recommended 10-15 gm of addition CHO before moderate activity or
about 20-30 gm before vigorous activity. They also should check their BG 30min before
and 1 hour after physical activity and adjust CHO accordingly.
Insulin and insulin analogs
Human insulin the mostly widely used one is synthesized from pork insulin or from
bacteria we recognize based on how fast they begin to work and hoe long they are active:
a) rapid acting-regular
b) intermediate acting -NPH and lente
long acting -ultralente
Insulin analogs- lispro
It is rapid acting human insulin. Regular human insulin has to be administered 30-45
minutes before meals. Lispro on the other hand is taken 5-10 minutes before meals. It
reduces after meal hyperglycemia to a greater extend and works 3 hour instead of 5-6
hours reducing thus the risk of hypoglycemia between meals and during the night.
The Honeymoon phase
It is temporary reminision of diabetes after initial treatment of diabetes with
insulin
Insulin delivery
a) by injection- mixture of two or more types of insulin three or more times daily
b) insulin pumps
Insulin and food intake
Insulin is administered to mimic body’s normal insulin action as closely as ;possible.
This involves administering NPH- intermediate acting insulin to meet base line needs
and regular -rapid acting insulin or insulin analog-lispro to cover energy nutrients
after meal.
Initially insulin is prescribed by physician based on individual needs which
is 0.5-1.0 unit of insulin per KG of body wt per day. Patients are then thought how to
adjust their individual insulin doses based on their level of physical activity, eating
pattern or health status.
Insulin and physical activity
Insulin should be take about an hour before physical activity.
Physical activity increases insulin absorption and may set the stage of hypoglycemia
for that reason it is advised to reduce insulin doses by 30 or even 50% to prevent this
from happening.
Mastering glucose control
Intensive therapy
Patient receives insulin 3-4 times a day and measures his blood 4 times a day. He is also
undergoing medical checkups once a month.
Regular therapy
Patient receives insulin once or twice a day and measure their blood glucose once a
day. They undergo medical checkups 3-4 times a year
Patients on both programs have measure hemoglobin A1c during their medical checkups.
A1c Glaciated hemoglobin is a measurement of glucose that reveals control of blood
glucose over past 2-3 months. Small glucose molecules attach themselves on hemoglobin
and remain detectable for the life span of red blood cells -120 days. Less than 6% is
desirable.
Blood glucose monitoring
Initially it is performed at least 7 times a day -before meal, 2 hours after each
meal and at bed time. This serves as tool to determined how BG responds to individual
meals , physical activity and general lifestyle-providing client adheres to his plan.
Once this is learned measurements may be performed less often.
Urinary ketones
Patient with consistently high BG is advised to monitor urinary ketones to prevent
development of coma resulting from high level of ketone bodies.
Managing hyperglycemia
Refer to table 27-5 on page 863
some possible solution may involve
-adjusting dose of regular insulin
- adding physical activity to the plan
- reducing amount of CHO at previous meal
- spacing the meal so the available insulin has time to work
Dawn Phenomenon
It is early morning hyperglycemia developing in response to contra regulatory
hormones-glucagon- that act to raise glucose level during an overnight fast.
Rebound hyperglycemia
Results from administering too much insulin initially. This drives glucose into
cells leaving patient with low level of BG. Body responds by secreting high levels of
contra regulatory hormones-glucagon to increase BG level to normal. BG however raises
too high causing hyperglycemia. Administering more insulin at this point only worsens
the situation. Treatment thus focuses on reducing the insulin dosages.
Illness
Even a minor illness may raise blood glucose dramatically. Physician may thus order
reduction of total energy and CHO to prevent need for extra insulin.
Severe Hyperglycemia and ketoacidosis
Thus can occur in patient with untreated IDDM or if patient with IDDM omits
insulin dose,makes an error in type of insulin, suffer stress0-infection or trauma that
cause blood glucose to raise.. It is a medical emergency and may lead to coma or death.
The best treatment here is prevention by education patient to follow the treatment
plan.
Managing Hypoglycemia
One of the disadvantages of tightly controlled BG is risk of hypoglycemia. It is
also known as insulin shock or insulin reaction. It can result from insulin overdose,
strenuous physical activity,skipped meal, or inadequate food intake.
As soon as symptoms appear person needs to receive 10-15 gm of CHO best glucose
tablets if not anything that don’t contain fat that slows down glucose absorption.
Check BG after 15-20 minutes if BG raised to acceptable level if not administer another
10-15gm of CHO. Continue until BG don’t raises to acceptable level.
Hypoglycemia before Meals
If it is consistent it indicates need to reduce the insulin dose prior meal.
Nocturnal hypoglycemia
It is hypoglycemia occurring during sleep. Strategies to prevent it include:
-avoid strenuous physical activity late in the day
-consume snack at bed time
-reduce insulin dose following evening activity
Treatment of non insulin dependent diabetes mellitus
The goals of therapy for NIDDM mimic those for IDDM:
• To achieve and maintain acceptable blood glucose levels, blood lipid concentrations,
a blood pressure.
• To prevent the acute and chronic complications associated with diabetes.
• To support quality of life by enabling people to Continue the activities they enjoy
with the best possible health.
DIET IN NIDDM
The diet for NIDDM is designed to maintain near-normal blood glucose by delivering a
balanced nutrient intake with carbohydrates spaced evenly throughout the day. . The diet
represents healthy eating for all people and is the same as for people with IDDM.
Timing and Distribution of Meals Providing a consistent carbohydrate intake
spaced throughout the day helps people with NIDDM maintain appropriate blood glucose
levels .Giving too much carbohydrate at one time can raise blood glucose too high,
stressing the already-compromised insulin-producing cells. Giving too little
carbohydrate can lead to hypoglycemia, especially for people on drug therapy (some oral
drugs or insulin).
Weight Control
Weight loss is often prescribed for people with NIDDM. Even moderate weight loss
(10 to 20 pounds) can help reverse insulin resistance, improve the blood lipid profile,
and reduce blood pressure The person at a healthy weight may not need to limit energy
intake, but still needs to follow the principles of the diet for diabetes.
Alcohol
The guidelines for alcohol use in NIDDM are the same as for IDDM .
Physical Activity
A regular program of moderate physical activity improves blood glucose control,
contributes to weight loss, improves blood lipid and lowers blood pressure in people
with NIDDM. It is recommended to exercise 20 to 30 minutes of low-impact aerobic
activity (such as walking) at least three day. Many clinicians believe that 80 to 90 per
cent of overweight people with NIDDM can achieve metabolic control by following a
calorie-restricted diet combined with a moderately intense physical activity program.
DRUG THERAPY IN NIDDM
When diet and physical activity fail to control blood glucose adequately, oral drugs
called anti-diabetic agents may be prescribed to lower blood glucose. Drugs do not
replace diet and physicalactivity. Advise clients to continue these therapies as
instructed.
Anti-diabetic Drugs
Summary
Diabetes in Pregnancy and Later Life
The hormones that oppose the action of insulin during late pregnancy are placental
lactogen,cortisol, prolactin, and progesterone.
DIABETES MANAGEMENT IN PREGNANCY
pregnancy elevates blood insulin and alters insulin resistance in all women. Blood
insulin begins to rise soon after conception, cells respond by storing energy
nutrients to provide for the developing fetus Later in pregnancy, insulin remains
high, but the cells become insulin resistant Hormones that act antagonistically to
insulin rise. This hormonal shift signals the body to stop storing energy fuels and
allows the fetus to rapidly take up energy nutrients.
Risks of Diabetes during Pregnancy
Women with diabetes who are contemplating pregnancy. should know that poorly controlled
diabetes before and during pregnancy presents risks for both mother and infant.28 Women
face a high infertility rate, and those who do conceive may experience episodes of severe
hypoglycemia or hyperglycemia, spontaneous abortion, and pregnancy induced hypertension.
infants also have increased mortality and morbidity.
Gestational Diabetes
Women who never had diabetes or never knew they had it may be diagnosed with diabetes
for the first time during pregnancy . Gestational diabetes is relatively common, and
the American Diabetes Association recommends that health care professionals screen all
women for diabetes between 24 and 28 weeks gestation.
Blood Glucose Monitoring
Ketosis in, early pregnancy can lead to congenital malformations, central nervous
system disorders, and low measures of intelligence in infants.
Diet Therapy
The diet plan aims to provide adequate but not excessive calories to support
weight gain Carbohydrate is often provided at lower amounts (40 to 45 percent of
calories) than in the usual diet for diabetes to keep blood glucose levels from rising
too high after meals.
Preventive Measures after Gestational Diabetes
For most women with gestational diabetes, glucose tolerance returns to normal
after pregnancy. Nevertheless, those with gestational diabetes are likely to develop
NIDDM later in life, especially if they are overweight. For this reason, health care
professionals encourage clients with gestational diabetes to avoid excessive weight
gain during pregnancy and to achieve or maintain a healthy weight thereafter.
DIABETES MANAGEMENT IN LATER LIFE
The elderly face special problems in dealing with diabetes. They have greater risks of
hyperglycemia and hypoglycemia because of reduced appetite, altered thirst regulation,
altered kidney and liver functions, depression or mental deterioration, multiple
medications, and other medical conditions.
Summary
Hypoglycemia
Strictly speaking, the term hypoglycemia simply means "low blood glucose" and it refers
not to a disease, but to a symptom of an alteration in carbohydrate metabolism.
There are two major types of hypoglycemia:
a) reactive
b) fasting.
REACTIVE HYPOGLYCEMIA
Reactive hypoglycemia occurs within an hour or two after eating and is triggered
by the release of the hormone epinephrine in response to rapidly falling blood glucose.
Symptoms of Reactive Hypoglycemia
The symptoms are similar to those of an anxiety attack: weakness, rapid heartbeat,
sweating,anxiety, hunger, and trembling. They are caused by the “emergency hormone,
epinephrine.
Diagnosis of Reactive Hypoglycemia
True reactive hypoglycemia can be identified by low blood glucose and the
simultaneous presence of symptoms. True reactive hypoglycemia is rare, although.
Carbohydrate-Modified Diet for Reactive Hypoglycemia
For people who experience true reactive hypoglycemia, avoiding both low
carbohydrate dieting (see p 243) and sudden large carbohydrate doses may be all that is
required The remedy,then is similar to the diet for diabetes eat a consistent amount of
carbohydrate from balanced meals at regular times. If average-sized meals fail to relieve
symptoms, smaller meals eaten more frequently may help.
FASTING HYPOGLYCEMIA
Fasting hypoglycemia: hypoglycemia that develops gradually and primarily affects
the brain and central nervous system.
Fasting hypoglycemia arises from medically diverse disorders, such as diabetes or
tumors of the pancreas or liver, that interfere with normal blood glucose regulation.
Symptoms of Fasting Hypoglycemia
The symptoms of fasting hypoglycemia differ from those of reactive hypoglycemia
because they are not related to epinephrine release. Instead, blood glucose falls slowly,
and the major effect is on the brain and central nervous system. The symptoms include
headache, blurred vision, mental dullness, fatigue, confusion, amnesia, and even seizures
and unconsciousness.
Carbohydrate-Modified Diets for Fasting Hypoglycemia
Surgery is the primary treatment of fasting hypoglycemia caused by tumors, although
carbohydrate-controlled diets (as described for reactive hypoglycemia) may be used
temporarily.
Summary
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