Section 3

Medical Nutrition Therapy

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Chapter 17
Diet and Diabetes Mellitus

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Objectives
Describe diabetes mellitus and identify the types Describe the symptoms of diabetes mellitus Explain the relationship of insulin to diabetes mellitus Discuss appropriate nutritional management of diabetes mellitus
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Diabetes mellitus
Glucose is the primary source of energy for the body. Glucose is transported by the blood, and its entry into the cells is controlled by insulin.

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Insulin
Secreted by the beta cells of the islets of Langerhans in the pancreas gland. When there is inadequate production of insulin or the body is unable to use the insulin it produces, glucose cannot enter the cells and it accumulates in the blood, creating hyperglycemia.

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Symptoms
Polyuria: excessive urination Polydipsia: excessive thirst Polyphagia: excessive appetite Loss of weight, weakness, fatigue

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Complications
Ketones: substances to which fatty acids are broken down in the liver. Ketoacidosis: condition in which acids from ketones accumulate. May lead to diabetic coma which can result in death if the client is not treated quickly with fluids and insulin.

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Complications
Atherosclerosis is a major cause of death in diabetics. Retinopathy is the leading cause of blindness in the United States. Kidney disease resulting in dialysis. Nerve damage (neuropathy) is not uncommon. Infections, especially of the urinary tract are frequent problems.
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Etiology
The cause of diabetes is unconfirmed although it is believed that it may be hereditary. Environmental factors may also play a role in the development of diabetes. Viruses or obesity may precipitate the disease.

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Classification
Type 1: insulin-dependent diabetes mellitus Type 2: non-insulin-dependent diabetes mellitus Gestational diabetes: diabetes in pregnancy

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Type 1
Formerly juvenile-onset diabetes mellitus. Occurs between the ages of 1 and 40. 10 to 20% of all diabetes cases. Secrete little, if any, insulin. Clients become insulin dependent requiring both insulin injections and a carefully controlled diet.

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Type 2
Previously called adult-onset diabetes. Usually occurs after age 40, new evidence suggests screening at age 25. Obesity epidemic has increased prevalence among young adults.

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Type 2
Treatment: diet, exercise, oral glucoselowering medication (may or may not need insulin). Goals of medical nutrition therapy include maintaining healthy glucose, blood pressure and lipid levels; weight reduction.

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Gestational Diabetes
Occurs between sixteenth and twentyeighth week of pregnancy. Insulin required if not responsive to diet and exercise. Usually, gestational diabetes disappears after the infant is born. Diabetes can develop 5 to 10 years after the pregnancy.
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Treatment
Goals:
Control blood glucose levels Provide optimal nourishment for the client Prevent symptoms and thus delay complications

Normal blood glucose levels are 70 to110 mg/dl.

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Treatment Regimes
Diet alone Diet combined with glucose-lowering medication Diet combined with insulin Exercise combined to any of the above Regularly monitor blood glucose levels in addition to any of the above
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Nutritional Management
Clients kcal needs will depend on age, activities, lean muscle mass, size and REE. Recommended:
Carbohydrates 50 to 60% of the kcal 40 to 50% from complex carbohydrates 10 to 20% from simple sugars

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Nutritional Management
It is the total amount of carbohydrates eaten that affects blood sugar levels rather than the type. Fats should be limited to 30% of total kcal. Proteins provide from 15 to 20% of total kcal.

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Carbohydrate Counting
Newest method for teaching a diabetic client how to control blood sugar with food. The starch/breads, milk, and fruits have all been put under the heading of carbohydrates. Exchange lists are utilized in carbohydrate counting as well as traditional meal planning.
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Diets Based on Exchange Lists

Most commonly used method of diet therapy is based on exchange lists. These lists were developed by the American Diabetes Association in conjunction with the American Dietetic Association.

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Diets Based on Exchange Lists

Foods within each list contain approximately equal amounts of kcal, carbohydrates, protein, fats. One food on a particular list can be substituted for any other food on that particular list and still provide the client with the prescribed types and amounts of nutrients and kcal.
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Diets Based on Exchange Lists

The amounts of nutrients and kcal on one list are not the same as those on any other list. The diet is given in terms of exchanges rather than as particular foods.

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Stop and Share

Use the exchange lists in your text starting on page 323 to identify the number of each exchange in the following meal. Turkey sandwich made with 4 oz extra lean turkey ham and 1 Tbsp reducedcalorie mayonnaise on reduced-calorie bread, 1.5 oz of pretzels, and iced tea.

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Stop and Share

Two slices reduced calorie bread: 1 starch exchange Turkey ham: 4 meat exchanges Mayonnaise: 1 fat exchange Pretzels: 2 starch exchanges Iced tea: Free (Total: 3 starch, 4 meat, 1 fat exchange)
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Fiber
High fiber intake appears to reduce the amount of insulin needed because it lowers blood glucose. It also appears to lower the blood cholesterol and triglyceride levels. High fiber may mean 25-35g of dietary fiber a day. Increase water when increasing fiber.
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Alternative Sweeteners
Saccharin has been shown to produce bladder cancer in rats when used in large quantities. Approved by FDA:
Aspartamemade from amino acids; does not require insulin for metabolism. Sucralosesweetener made from sugar molecule.
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Dietetic Foods
Use of diabetic foods is generally a waste of money and can be misleading to the client. Often the containers of foods will contain the same ingredients as containers of foods prepared for the general public. These foods will contain carbohydrates, fats, and proteins that must be calculated in the total days diet. Read the label!
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Alcohol
Not recommended for diabetic clients. Limited use sometimes allowed if approved by physician. Some diabetic clients who use hypoglycemic agents cannot tolerate alcohol. Include in diet plan if used.

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Exercise
Type 2: exercise helps improve weight control, glucose levels, and the cardiovscular system. Type 1: exercise can complicate glucose control. If done, should be on regular basis, and considered carefully as meals are planned to avoid hypoglycemia.

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Insulin Therapy
Clients with type 1 diabetes must have injections of insulin everyday to control blood glucose levels. Must be injected because it is a protein and would be digested if swallowed. Human insulin most common and preferred; made synthetically.

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Insulin Therapy
Beef or pork insulin available. Not as commonly used because antibodies in them make them less pure than human. Insulin classified by action: very rapid-, rapid-, intermediate- and long-acting. Intermediate types work within 2 to 8 hours and are effective 24 to 28 hours.

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Insulin Therapy
Shorter and longer-acting insulin may be given together and more than one injection a day may be required. Insulin pumps are now available and can deliver short-acting continuous dose and pre-meal boluses.

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Insulin Therapy

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Insulin Reactions
Insulin reaction, or hypoglycemic episode, can result from too much insulin. Symptoms include headache, blurred vision, tremors, confusion, poor coordination, eventual unconsciousness. Brain damage, coma, or death may result.

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Treatment for Insulin Reactions

Conscious clients may be treated by giving them a glucose tablet, a sugar cube, or a beverage containing sugar followed by a complex carbohydrate. Unconscious clients require intravenous treatment with dextrose and water. Diabetic clients should carry identification.

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Considerations for Health Care Professional

If diet is followed, medication is taken, and time is allowed for sufficient exercise and rest, one can live a near-normal life. Emphasize importance of eating all of the prescribed food. Meals should be eaten at regular times, and clients should read labels.

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Conclusion
The diabetic diet is used in treating diabetes mellitus, a metabolic disease caused by the improper functioning of the pancreas. Serious complications, including death, can occur if condition is left untreated. Treatment includes diet, medication, and exercise.
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