1. Hanadi Baeissa Disturbance in Glucose Utilization Diabetes Mellitus- Gestational Diabetes- Impaired Glucose Tolerance- Hypoglycemia

2. Hanadi Baeissa Diabetes Mellitus There are two types of diabetes mellitus:  Type I, or insulin dependent (IDDM)  Type II, or non-insulin dependent (NIDDM)

3. Hanadi Baeissa

4. Gestational Diabetes A temporary type of diabetes that occurs during pregnancy

5. Hanadi Baeissa Impaired Glucose Tolerance A higher than normal blood glucose level that is below the accepted value to diagnose diabetes Diet therapy is essential for all types of disturbance in glucose utilization

6. Hanadi Baeissa The Goals of Diet Therapy for Diabetes 1. Attain and maintain desirable body weight. 2. Provide a normal growth rate in children and pregnant women. 3. Minimize glycosuria and keep the plasma glucose as near normal physiological range as possible. 4. Prevent and/or delay the development and/or progression of cardiovascular, renal, retinal, neurological, and other complications associated with diabetes.

7. Hanadi Baeissa 5. Modify the diet as necessary for complications of diabetes and for associated diseases 6. Improve the overall health of the patient by attaining and maintaining an optimal nutritional status. 7. Provide for each patient an individualized educational and follow- up program.

8. Hanadi Baeissa Nutrition Guidelines 1. Type 1 diabetes: i. Take diet history usual pattern of food intake and physical activity ii. Develop an individualized meal plan and schedule of insulin therapy iii. Emphasize the need for regular meal and snack schedule + SMBG

9. Hanadi Baeissa iv. Synchronize food intake with the time of action of the insulin used, and teach patient to change dosage and time of administration to compensate for changes in the meal plan

10. Hanadi Baeissa 2. Type 2 diabetes: i. Take diet history usual pattern of food intake and physical activity ii. Aim to reduce weight iii. Reduce fat intake iv. Encourage physical activity v. Emphasize the need to control BG, lipid levels and BP by dietary means, explaining how to do so vi. Develop an individualized meal plan

11. Hanadi Baeissa 3. Diabetes in Pregnancy: A- Diabetic women who become pregnant: i. Intensive therapy is indicated ii. SMBG must be conducted iii. Changing meal plan with advancing pregnancy to maintain fatal growth iv. Restrict energy intake for obese women (BMI > 30) v. Encourage physical activity v. Monitor urine for ketones

12. Hanadi Baeissa B- GDM i. Provide adequate calories and nutrients to promote normal fetal growth ii. Plan meal times to maintain FBG at ≤ 95 mg/dl or 2h PPG at ≤ 120 mg/dl + SMBG iii. Bed time snack may be recommended to reduce risk of hypoglycemia at night iv. Restrict energy intake for obese women (BMI > 30) v. Encourage physical activity v. Monitor urine for ketones

13. Hanadi Baeissa Dietary management of impaired glucose tolerance 1. Weight loss if needed 2. Avoidance of concentrated sweets and fats 3. Increase level of exercise 4. Increase intake of soluble fiber incase of hyper-triglyceridemia

14. Nutritional Management of DM Meal planning:  Balanced meals are essential  Meals should include a source of protein to slow digestion, and the increase in blood sugar  Complex carbohydrates are preferred, while simple sugars avoided  Carbohydrates should be divided carefully between meals and snacks

15. Hanadi Baeissa Some Complications of Diabetes Nutritional Management

16. Hanadi Baeissa Insulin Shock or Insulin Reaction & Hypoglycemia Causes:  More insulin is injected or more oral hypoglycaemic agents are given than needed  Foods are omitted from diet  Increased physical activity  An error in insulin injection in relation to exercise

17. Hanadi Baeissa

18. Symptoms: Blood glucose decreases below acceptable level and patient sweats profusely If not treated promptly the patient experiences :  Mental confusion and disorientation  If untreated seizures occur followed by  unconsciousness and  Death

19. Prevention and Management Avoid precipitating factors Recognize signs Test BG Correct hypoglycaemia If the patient is unconscious glucagon injections must be given

20. Hanadi Baeissa

22. Coping with acute illness Check BG and urine ketones often Consume 10-15 gm CHO every 1-2 hours When vomiting, diarrhea or fever present consume liquids every 15-30 min. Notify health care provider if cannot retain food for ≥ 4h.

23. Hanadi Baeissa

24. Other complications of DM Heart disease- control fat & cholesterol intake Kidney disease- control protein intake Diabetic retinopathy- control BG and take anti-oxidants Neuropathy- control BG and take vit.B 1,B 6 and B 12 supplement

25. Hanadi Baeissa Coping with gastroparesis Give drugs to increase GI motility Correct hyperglycemia if present Keep record for food, BG, and symptoms to fit insulin to peak absorption time Use short and ultra-short insulin Decrease fat intake

26. Hanadi Baeissa Decrease intake of high fiber food Give small frequent meals Chew well Maintain upright posture for 30-60 min after meal

27. Hanadi Baeissa Role of the nurse in nutritional management of diabetes 1. Review previous history and diet 2. Give positive verbal reinforcement for any attempt at control 3. Identify areas of strength for positive reinforcement and areas of need for referral or personal assistance 4. Assess the patient’s knowledge about his/her condition, and explain appropriate action in various situations

28. Hanadi Baeissa Reactive Hypoglycaemia Postprandial Second most common type of hypoglycaemia Caused by exaggerated insulin release following a meal leading to transient hypoglycaemia. Glucose returns to normal without food.

29. Hanadi Baeissa

30. Dietary management of reactive hypoglycemia 1. Limit the intake of simple sugars, and conc. Sweets 2. Emphasize complex carbohydrates 3. Eat small frequent meals and snacks (every 2 to 3 hours) 4. Include a protein source with meals and snacks 5. Restrict intake of caffeine

31. Hanadi Baeissa

32. How to approximate the individual dietary needs

33. Hanadi Baeissa Factors to consider: i. Weight and height ii. Caloric needs iii. Division into protein, carbohydrate and fat iv. Division into meals and snacks v. Limitations (modifications for special condition) vi. Need for insulin vii. Individual food habits viii. Family food budget

34. Hanadi Baeissa Weight and height ChildrenMenWomenBuild Chart growth pattern on graph (Wetzel, Lowa, or Stuart) every 3-6 months Allow 106 Ib. for first 5 ft. of height, plus 6 Ib. for each additional inch Allow 100 Ib. for first 5 ft. of height, plus 5 Ib. for each additional inch Medium Subtract 10% Small Add 10% Large

35. Hanadi Baeissa Determination of caloric needs For adults 1. Basal calories equals desirable body weight (Ib.) x 10, or (Kgx 22) 2. Add activity calories a. Sedentary equals desirable body weight (Ib.) x 3, or ( Kg x 6.6) b. Moderate equals desirable body weight (Ib.) x 5, or (Kg x11) c. Strenuous equals desirable body weight (Ib.) x 10, or (Kgx22)

36. Hanadi Baeissa 3. Add calories for indicated weight gain, growth (pregnant women), or lactation 4. Subtract calories for indicated weight loss

37. Hanadi Baeissa For children 1. Children vary markedly in their caloric needs depending on rate of growth and level of activity 2. Estimate caloric requirement from chart of Recommended Daily Dietary Allowances 3. Adjust caloric intake as needed to maintain normal rate of growth

38. Hanadi Baeissa Determination of grams of protein, carbohydrate and fat a. Protein: 20% of total calories for growing children and pregnant women, minimum of 0.5 gm per Ib.(1.1 gm/Kg)desirable body weight for other adults b. Carbohydrate: from 50-70% of non- protein calories c. Fat: from 30-50% of non-protein calories

39. Example for diet order of 2000 kcal /day Protein: 2000x0.15=300 kcal ÷4(kcal/g)=75g Carbohydrate: 2000x0.6=1200 kcal ÷ 4(kcal/g)=300g Fat: 2000x0.25=500 kcal ÷ 9(kcal/g)=55g

40. Hanadi Baeissa Suggested division into meals and snacks a. Meals usually contain 2/10 to 4/10 of the calories and carbohydrate, and snacks usually contain 1/10 of the calories and carbohydrate

41. b. In the non-insulin dependent individual, food is usually divided into three meals per day. In the insulin dependent individual, food is usually divided into three meals and a bedtime snack and occasionally a mid- afternoon and/or mid-morning snack, depending on plasma glucose levels

42. Hanadi Baeissa Limitations (modifications for special conditions) a. Protein b. Saturated fat and/or cholesterol c. Sodium d. Potassium e. other

43. Hanadi Baeissa

45. The GI Factor The increase in the area under the blood glucose curve after the ingestion of 50 gm of carbohydrate in the test food compared to the area under the curve when 50 gm of glucose or white bread is taken

46. Hanadi Baeissa