Beruflich Dokumente
Kultur Dokumente
Transition to Insulin
Aurielle Lowery, Sarah Liu, Sarah Vacher, and Xiaolu Hou
Source: http://www.slideshare.net/reliablerxpharmacy/r-rx-diabetes
Objectives
Diabetes Prevalence
Age
Overweight/obesity
Issues During
Pregnancy
Hypertension
Family history
Ethnicity
Hypercholesterolemia
Source: http://diabetes.niddk.nih.gov/dm/pubs/diagnosis/#3
Polycystic ovary
syndrome
Pre-diabetes
Acanthosis nigricans
Sedentary
Sleep disorders
Waist
circumference
B. Diabetic dermopathy
C. Type 1 diabetes
D. Insulin resistance
Source: http://www.greenexamacademy.com/wp-content/uploads/theme-uploads/leed-practice-exam.jpg
Nutrition Assessment
Glucose Metabolism
Glycogenolysis
Gluconeogenesis
Diet
Lactate
Pyruvate
Amino acids
Glycerol
Plasma
Glucose
Source: Chapter 2: Normal Glucose Homeostasis from Principles of Diabetes Mellitus. doi: 10.1007/978-0-387-09841-8_2
Glucose Metabolism
Oxidative
Acetyl CoA,
Krebs Cycle
ENERGY!
Non-oxidative
Lactate or
Alanine Formation
Gluconeogenesis
Glycolysis
Plasma Glucose
Glycogen storage
Source: Chapter 2: Normal Glucose Homeostasis from Principles of Diabetes Mellitus. doi: 10.1007/978-0-387-09841-8_2
Regulating Glucose
Glucose must stay within a tight range
Insulin promotes glucose uptake in tissues
Hormones that increase plasma glucose:
Glucagon
Catecholamines
Cortisol
Growth hormone
Non-hormonal factors:
Diet, exercise, other substrates (FFAs)
Sources: Chapter 2: Normal Glucose Homeostasis from Principles of Diabetes Mellitus. doi: 10.1007/978-0-387-09841-8_2
http://www.diabetes.co.uk/images/article_images/glucose.jpg
Lipotoxicity
Lipolysis, circulating free fatty acids (FFAs)
Decreases glucose utilization, increases gluconeogenesis
Also oxidative stress, apoptosis
Diagnostic Criteria
A1C > 6.5%
Fasting plasma glucose > 126 mg/dL
2-hour BG post OGTT > 200 mg/dL
If random blood sugar draw is > 200 mg/dL
with symptoms of diabetes
Sources: http://diabetes.niddk.nih.gov/dm/pubs/diagnosis/#3
http://www.hrmc.org/news_photos/diabetic.jpg
D. Fasting PG >100 mg/dl, A1c >6.5%, OGTT >200 mg/dl with symptoms
of diabetes, and/or casual PG > 200 mg/dl with symptoms of diabetes
Source: http://www.greenexamacademy.com/wp-content/uploads/theme-uploads/leed-practice-exam.jpg
Heart
Kidneys
Complications of LT Diabetes
Eyes
Cataracts
Glaucoma
Retinopathy
Kidney disease
Swelling of hands,
feet, face
Edema
Itchiness and/or
drowsiness
Complications of LT Diabetes
Poor wound healing
Amputations
Nerve damage
Sexual dysfunctional
Numbness or burning
pain
Neuropathy
Gastroparesis
Postural hypotension
Diarrhea
Peripheral/autonomic
nerve damage
Sources: http://my.clevelandclinic.org/health/diseases_conditions/hic_Diabetes_Basics/hic_Long-Term_Problems_for_People_with_Diabetes
http://www.podiatrypractice.com.au/wp-content/uploads/2013/03/diabetic-foot-ulcer.jpg
B. Diabetic dermopathy
C. Granuloma annulare
D. Diabetic thick skin
Source: http://www.greenexamacademy.com/wp-content/uploads/theme-uploads/leed-practice-exam.jpg
Abdominal pain
Acidosis hallmark (pH
and bicarbonate)
Can occur in <24 hours
Occurs in type 1 diabetic
patients
Little or no ketones
Acidosis not present
Kussmaul respirations
Source: http://care.diabetesjournals.org/content/27/suppl_1/s94.full
Source: http://www.aafp.org/afp/2005/0501/p1723.html#afp20050501p1723-b6
Stressful event
Congestive heart failure
Poor kidney function
Impaired thirst
Limited access to water (coffee and diet soda, no water
consumption reported)
Older age
Poor management of diabetes
Stopping insulin or other prescribed drugs
Certain medications (dyazide diuretic)
Sources: http://www.aafp.org/afp/2005/0501/p1723.html#afp20050501p1723-b6
http://www.nlm.nih.gov/medlineplus/ency/article/000304.htm
Mitchs Values
>600 mg/dL
1524 mg/dL
>7.30
----
Ketonuria
Negative
Positive
Potassium
3.9 mEq/L
Creatinine
1.9 mg/dL
5 20 mg/dL
31 mg/dL
39-49% (M)
57%
135-153 mEq/L
156 mEq/L
Parameters
Blood glucose
Serum osmolarity
pH
BUN
Hct
Sodium
Source: http://www.aafp.org/afp/2005/0501/p1723.html#afp20050501p1723-b6
HHS - Treatment
Sources: http://www.aafp.org/afp/2005/0501/p1723.html#afp20050501p1723-b6
Guillermo E. Umpierrez et al. Diabetes Spectr 2002;15:28-36
53 year old M
Pts Weight: 214# (97.3 kg)
Height: 59 (175 cm)
Body Mass Index: 31.8 (Obesity, class 1)
Mitchs Values
<7%
15.2%
70 130 mg/dL
1524 mg/dL
Peak post-prandial
plasma glucose
<180 mg/dL
----
LDL
<100 mg/dL
123 mg/dL
TG
<150 mg/dL
185 mg/dL
HDL
>40 mg/dL
55 mg/dL
129/92 mm Hg
Parameters
Hb A1C
Pre-prandial plasma
glucose
BP
Accuchecks:
Monitoring of daily BG patterns
Typical test times
Before meals
After meals (1-2 hrs)
Bedtime (HS)
Overnight
Source: www.diabeteshealth.com
Treatment
Shakiness, anxiety
Diaphoresis
Palpitations
Hunger
Confusion
Slurred speech
Seizures
Loss of consciousness
Coma / Death
-Glucosidase Inhibitors
Biguanides
Premixed insulin
Pulmonary insulin
IV insulin
Rapid-acting
Short-acting
Intermediate-acting
Long-acting
Significant to Determine:
Insulin-to-carb ratio
Continuous insulin
administration
Sources: http://www.greenexamacademy.com/wp-content/uploads/theme-uploads/leed-practice-exam.jpg
http://www.testprepreview.com/certifieddiabeteseducator.htm
Sources: http://www.greenexamacademy.com/wp-content/uploads/theme-uploads/leed-practice-exam.jpg
http://www.studyguidezone.com/cde.htm
Nutrition Diagnosis
Mitchs Values
<7%
15.2%
70 130 mg/dL
1524 mg/dL
Peak post-prandial
plasma glucose
<180 mg/dL
----
LDL
<100 mg/dL
123 mg/dL
TG
<150 mg/dL
185 mg/dL
HDL
>40 mg/dL
55 mg/dL
129/92 mm Hg
Parameters
Hb A1C
Pre-prandial plasma
glucose
BP
Source: NCM
Lets Practice!
Write an example PES statement given the following
information about our case study patient:
Male, 53 yo
Mildly obese
Glucose: 475 mg/dl
BUN: 20 mg/dl
A1C: 15.2%
Pt has never had diabetes education except what physician has told him.
Typical intake: often eats out, makes meals high in carbohydrates, avoids sweets.
Pt lives alone and is noncompliant with diabetes medications.
Never received diabetes education except for what physician told him at onset
Dx: Uncontrolled DM with HHS.
Source: http://www.conci.com/wp-content/uploads/2012/12/What-Your-Dietitian-Does-for-Exercise.jpg
Nutrition Intervention
SPECIFIC GOALS:
of A1C by 1% in pts w/ newly dx T1DM
of A1C by ~2% in pts w/ newly diagnosed T2DM
of A1C by 1% in pts w/ T2DM of 4 yrs
LDL-C by 15-25 mg/dL in 3-6 months
Source: http://care.diabetesjournals.org/content/35/2/434.full
Source: http://mattgoss.la/wp-content/uploads/2010/01/video-icon.jpg
ENERGY NEEDS:
MACRONUTRIENT NEEDS:
CHO 45-65%
Protein 10-35%
Fat 20-35%
Source: http://bed56888308e93972c04-0dfc23b7b97881dee012a129d9518bae.r34.cf1.rackcdn.com/sites/default/files/20946-308.jpg
Cut back on added fats as well as salty, convenience, and fast foods
Sources: http://www.liftingrevolution.com/wp-content/uploads/2013/03/weight-loss-women.jpg
NCM Type 2 Diabetes
Breakfast
CHO
Choices
Lunch
CHO
Choices
Dinner
CHO
Choices
Snack
CHO
Choices
Total
Protein
Choices for
the Day
Total Fat
Choices For
the Day
1200
3 = 45 gm
2 = 30 gm
2 = 30 gm
2 = 30 gm
5 = 35 gm
3 = 15 gm
1500
3 = 45 gm
3 = 45 gm
3 = 45 gm
2 = 30 gm
6 = 42 gm
4 = 20 gm
1800
4 = 60 gm
4 = 60 gm
4 = 60 gm
2 = 30 gm
6 = 42 gm
6 = 30 gm
2000
4 = 60 gm
4 = 60 gm
4 = 60 gm
3 = 45 gm
7 = 49 gm
6 = 30 gm
2200
5 = 75 gm
4 = 60 gm
4 = 60 gm
3 = 45 gm
8 = 56 gm
7 = 25 gm
2400
5 = 75 gm
5 = 75 gm
5 = 75 gm
3 = 45 gm
9 = 63 gm
8 = 40 gm
2800
6 = 90 gm
6 = 90 gm
6 = 90 gm
4 = 60 gm
9 = 63 gm
9 = 45 gm
3000
6 = 90 gm
6 = 90 gm
6 = 90 gm
5 = 75 gm
10 = 70 gm 10 = 50 gm
Limited time and/or ability to plan for and prepare appropriate food
choices
Alcohol use
Nutrition Monitoring
& Evaluation
Monitoring and
Evaluation in the
Hospital Setting
Metabolic Control
Food Intake
Medications
Weight loss is NOT a
primary goal
Source: http://www.medscape.com/viewarticle/832289
Metabolic control
Food Intake
Physical activity & exercise
Anthropometric Measurements
Medications
Pertinent lab values
Questions / Comments?
Source: http://cdn2.hubspot.net/hub/38219/file-13929501-jpg/images/fotolia_14605019_xs.jpg