1. Williams’ Basic Nutrition and Diet Therapy Chapter 20
Diabetes Mellitus
Williams’ Basic Nutrition and Diet Therapy
Chapter 20

2. Diabetes Mellitus Definition:
Diabetes mellitus refers to a group of metabolic diseases that are characterized by an excessively high (hyperglycemia) blood glucose level
Disruption of metabolism of carbohydrates, proteins, and fats

3. Diabetes Mellitus Incidence
246 million people worldwide have diabetes
20.8 million Americans have diabetes (7% of population)
Estimated total cost of diabetes in US was $174 billion in 2007 (32% increase since 2002)
Seventh most common cause of death in US (mainly due to CV disease)

4. Diabetes Mellitus Incidence
African American, Native American, Latin American, and Asian Americans have a 3 times higher incidence than Northern European Americans
Increased incidence with aging:
> 33% over age of 60
Males/females equally affected

5. History of Diabetes Symptoms date back to about 1500 BC
Diabetes is Greek meaning siphon
Mellitus is Latin for honey
Insulin comes from the Latin word insula meaning island
Paul Langerhans found special clusters of cells called islets of Langerhans in the pancreas

6. Islets of Langerhans Cells
Special groups of cells in the pancreas called alpha, beta, and delta cells
Make and secrete the following hormones that work together to regulate blood glucose levels:
Insulin, Glucagon, and Somatostatin

7. Insulin
A peptide (chain of amino acids) hormone produced in the beta cells of the islets of Langerhans in the pancreas
Transports glucose into cells for energy and storage as glycogen in liver and muscles
Stimulates free fatty acid storage in fat deposits
Stimulates protein synthesis (anabolic hormone)

8. Glucagon
A peptide hormone produced in the alpha cells of the islets of Langerhans in the pancreas
The effect of glucagon is reciprocal to that of insulin - it raises blood glucose levels by causing the breakdown of glycogen in the liver.
It protects the brain and other tissues during sleep and fasting.

9. Somatostatin
A peptide hormone produced in the delta cells of the islets of Langerhans in the pancreas
It tells the body when to make insulin and glucagon

11. Types of Diabetes Mellitus
Prediabetes
Type 1 Diabetes
Type 2 Diabetes
Gestational Diabetes
Diabetes due to other causes

12. Prediabetes
Characterized by blood glucose levels higher than normal yet not high enough to be diagnosed
Before contracting diabetes mellitus people usually have prediabetes:
Family history of diabetes mellitus
Hypertension
History of gestational diabetes
Low HDL and high LDL levels
Overweight/obesity

13. Types of Diabetes Mellitus
Type 1 Diabetes Mellitus
- Formerly known as juvenile onset diabetes or insulin-dependent diabetes mellitus
Type 2 Diabetes Mellitus
- Formerly known as adult onset or non insulin-dependent diabetes mellitus

14. Type 1 Diabetes Mellitus
Autoimmune disease (an attack initiated by the body's immune system against its own tissues) that effects the beta cells of the pancreas
Beta cells do not produce insulin or they produce it in small amounts that the body cannot use glucose (blood sugar) for energy

15. Type 1 Diabetes Mellitus
Genetic predisposition to this disease or a virus may have affected the pancreas
Typically occurs in people age 30 years of age and younger
In most cases, in girls and in boys

16. Type 1 Diabetes Mellitus
Insulin injections required
Different forms of insulin:
Short, medium, and long acting
Insulin pumps worn on hip like a beeper and attach to a long catheter that can release insulin directly into the body through a small needle that is left in the skin
Insulin pump is more convenient than injections
Some success has occurred with stem cell transplants

17. Type 1 Diabetes Dietary Strategy
Individuals need to consume meals and snacks at regular intervals each day
A person should consume a simple carbohydrate if blood glucose level is less than 100 mg per dl
The simple sugar will be quickly absorbed into the bloodstream
People with diabetes should carry high-carb foods with them all of the time-while exercising, in the car, at work…

18. Type 1 Diabetes Overview
Age of Onset:
Body Weight:
Treatment:
Dietary Strategy:
Insulin Dependent
Usually <30 Years old
Usually Low
Insulin Injections
Increase Calories, Meal Frequency with Proper Nutritional Balance

19. Type 2 Diabetes Mellitus
The pancreas does produce insulin, but the number of insulin receptors may be down regulated (a decrease in the number of receptors on the surface of target cells, making the cells less sensitive to a hormone) , resulting in decreased tissue sensitivity to insulin
Typically a comorbidity (concurrent health conditions) of overweight and obesity

20. Type 2 Diabetes Mellitus
Usually occurs after the age of 40, but increased rate of obesity in all ages
People can usually manage the disease by losing weight
Many people take oral hypoglycemic agents:
For example: Metformin or glucophage
Some may require insulin

21. Type 2 Diabetes Dietary Strategy
If weight loss recommended, decrease total daily caloric intake
Decrease portion size
Increase meal frequency
Minimize high starchy foods
Increase fiber intake
Limit sweets, sugars and sugar substitutes
Limit or eliminate alcohol consumption

22. Type 2 Diabetes Challenge
Try this next time you dine out!
Ask the waitperson the carbohydrate content of each item you order
Try to avoid starchy foods like bread, potatoes & rice
Be cautious with or avoid any rich sauces or gravies
Choose fiber- rich vegetables (watch the butter!)
Eat half your portion (box the rest!)
Limit yourself to one alcoholic beverage
No dessert!!!

23. Type 2 Diabetes Overview
Age of Onset:
Body Weight:
Treatment:
Dietary Strategy:
Insulin Resistant
Usually >40 Years old
Usually Overweight
Weight Loss, Exercise, Oral Hypoglycemic agents
Decrease Calories with Proper Nutritional Balance

24. Gestational Diabetes
Characterized by high blood glucose levels during pregnancy
All diabetic symptoms usually disappear following delivery
Treatment for gestational diabetes includes special diet, exercise, and insulin injections

25. Diabetes Due to Other Causes
Metabolic Syndrome- Following conditions must be present:
Obesity: abdominal obesity greater than 40 inches in males and 35 inches in females
Blood Pressure greater than 130/85mmHg
Fasting blood glucose levels >110 mg per dl
HDL cholesterol levels: <40 mg per dl in men and <50 mg per dl in females
Triglyceride levels: >150 mg per dl

26. Diabetes Due to Other Causes
Genetic defects
Pancreatic Conditions or Disease
Endocrinopathies (Hormone Dysfunction)
-Cushing’s Syndrome
-Pheochromocytoma
-Aldosteronoma
Drug or Chemical Induced Diabetes

27. Medical Diagnosis of Diabetes Mellitus
Primary tests used:
Fasting plasma (blood) glucose test (FPG)
Oral glucose tolerance test (OGTT)
FPG is assessment of blood glucose levels when a person has fasted
The OGTT is measured both at fasting and then 1 and 2 hours after consumption of a glucose beverage (50 g)

28. Medical Diagnosis of Diabetes Mellitus
Fasting plasma glucose > 126 mg/dl after no caloric input for at least 8 hr. or
Classic symptoms of diabetes + glucose level > 200 mg/dl
2-hour postload glucose > 200 mg/dl during an oral glucose tolerance test

29. Medical Diagnosis of Diabetes Mellitus
OGTT
FPG

30. Signs and Symptoms of Diabetes Mellitus
Polyuria:
increased frequency of urination
Polydipsia:
increased thirst
Polyphagia:
increased appetite
Lethargy:
general weakness

31. Signs and Symptoms of Diabetes Mellitus
Repeated infections or sores that heal slowly or not at all
Blurred vision
Tingling or numbness in hands or feet
Ketoacidosis

32. Ketoacidosis
The body cannot use glucose for energy because little or no insulin is present to deposit glucose into cells
Body starts to break down its fat stores for energy
Although fat has more energy than carbohydrates excessive breakdown of fat leads to a buildup of ketone bodies

33. Ketoacidosis
The CNS can use ketone bodies for a short time (prefer glucose) but the build up of ketone bodies makes the blood more acidic and results in ketoacidosis:
A life-threatening condition in which ketones (result from the breakdown of fat for energy) accumulate in the bloodstream and the pH of the blood decreases
May lead to a coma and possibly death
Moderate or large ketones are present in the urine as well as in the body

34. Measuring for Ketones
A blood test is the most accurate method of measuring ketones
A urine test is the most commonly used method of measuring ketones

35. Low Carbohydrate Diets
The goal of high protein low carbohydrate diets is to increase ketone production in the body
The negative effect of high ketone bodies is that they will not sustain the energy needed for the brain and spinal cord which prefers glucose
Ketoacidosis may occur, which may lead to a coma

36. Low Carbohydrate Diets
Q: Does ketosis help lose weight?
A: Yes.
Q: Is it safe?
A: I wouldn't recommend it. I think it is a dangerous way to lose weight.

37. Long Term Complications of Uncontrolled Diabetes Mellitus
Retinopathy:
Disease of the eyes that can lead to blindness
Diabetes mellitus is the leading cause of blindness in people 20 to 74 years of age
Nephropathy:
Disease of the kidneys that can lead to kidney failure
Heart Disease (HTN/Dyslipidemia/CAD)

38. Long Term Complications of Uncontrolled Diabetes Mellitus
Neuropathy:
Disease of the peripheral nervous system that can cause loss of sense of feeling, which often leads to wounds that never heal because the person does not feel them.
Amputations may result if these infections result in gangrene

39. Exercise Clearance
Before beginning an exercise program, clients with diabetes mellitus should have medical clearance from their physician
Exercise enhances the absorption of insulin, increases the muscle uptake of glucose, and impairs the mobilization of glucose in blood

40. Glycemic Control and Exercise
Moderate to intense activity may cause blood glucose levels to decrease after 24 hours
If blood glucose levels are less than 100 mg per dl immediately after exercise the individual should do the following:
Increase carbohydrate intake before exercise
Decrease insulin dosage following exercise
Consume a carbohydrate and protein snack

41. Hypoglycemia
The major goal is to prevent hypoglycemia (blood glucose level of 65 mg per dl or lower) as a result of exercise
Recommendations:
Measure blood glucose before, during, and after exercise
During exercise, easily absorbable carbohydrate may have to be consumed
After exercise, an extra carbohydrate-rich snack may be necessary
Consume 15g of carbohydrate if not planning to eat minutes before exercise
Take in 15 grams of carbohydrate and 7 grams of protein if not planning to eat for more than 60 minutes before exercise

42. Hypoglycemia During Exercise
May be caused by:
Increased exercise intensity
Longer exercise duration
Inadequate caloric intake prior to exercise
Not eating on time
Missing meals
Taking too much insulin
Insulin injection into exercising muscle
Colder environmental temperatures

43. Hypoglycemia Emergency situation (consider calling 911)
If blood glucose levels drop the individual may become confused, disoriented, or lose consciousness
Greater concern for clients with type 1 diabetes mellitus

44. Signs and Symptoms of Hypoglycemia
Blurry vision
Tachycardia
Dizziness
Confusion
Convulsion
Syncope (fainting)
Unconsciousness
Coma
Sweating
Cold clammy or sweaty skin
A staggering gait
Abdominal pain or nausea
Excessive hunger
Headache
Shaking or shivering
Irritability, hostility

45. Responding to a Client Who Has Hypoglycemia
Clients with diabetes should always wear a medical alert bracelet in case of a hypoglycemic reaction
Do not leave client alone
Measure blood glucose level with a glucose monitor device if available
Give sugar immediately!

46. Responding to a Client Who Has Hypoglycemia
If blood glucose level is below 70 mg per dl, provide 15 g of carbohydrate, which is equivalent to:
About 3-4 glucose tablets
3 packets of table sugar dissolved in water
½ cup of fruit juice or soft drink
6 life savers
1 tablespoon of honey
6 saltine crackers
Wait minutes, treat again and remeasure glucose level until blood glucose level rises above 70 mg per dl.

47. Hyperglycemia
High blood glucose levels due to too much food, not enough insulin, illness, or stress
Do not give sugar if individual is unconscious, having a seizure, or unable to swallow
Call 911!

48. Signs and Symptoms of Hyperglycemia
Nausea
Drowsiness
Blurry vision
Vomiting
Extreme thirst
Frequent urination

49. Contraindications to Exercise
Blood glucose levels greater than 240 mg per dl and ketones in urine for type 1 diabetes
Blood glucose greater than 300 mg per dl without ketones
Clients with retinopathy should avoid strenuous high intensity activity
Severe kidney disease
Clients with a loss of protective sensation in the feet should avoid outdoor walking and jogging. Swimming and biking is recommended.
Acute illness, infection, or fever
Evidence of underlying cardiovascular disease that has not been medically evaluated

50. Guidelines For Safe Exercise
Do not exercise when insulin is working at peak action
Don’t inject insulin into a part of the body you will be exercising. It will be absorbed faster there.
Eat a small snack or drink fruit juice minutes before exercising if blood sugar levels are below 100mg/dL
The personal trainer should not give advice to the client about the use of insulin or timing of meals

51. Benefits of Exercise Improved insulin sensitivity
Improved blood lipids and lipoproteins
Increased caloric expenditure resulting in reduction or maintenance of body weight, reduction in body fat, and preservation of lean body mass
Improved physical fitness
Improved flexibility and strength
Decreased BP in those with hypertension
Decreased risk of cardiovascular disease
Improved psychological well-being, including enhanced quality of life, improved self esteem

52. Aerobic Conditioning Guidelines for People with Diabetes Mellitus
Frequency: 4-6 days or daily
Duration: minutes
40-70% VO2
Monitor exercise intensity via RPE
A snack may be needed before exercise
Monitor blood glucose before and after exercise
Include a 5-10 minute warm-up and cool-down period
Large muscle activities

53. Resistance Training for People with Diabetes Mellitus
Frequency: 2-3 nonconsecutive days/week
Muscular Endurance: 1-3 sets/10-15 reps
Up to 8-10 exercises
Can begin with body weight exercises and progress to free weights and machines
Clients with well controlled diabetes can progress to strength training

54. Flexibility Training for People with Diabetes Mellitus
Minimum of 2-3 sessions per week
Hold static stretches for seconds
Yoga is a good example for flexibility training

55. Basic Elements of Diabetes Management
Healthy diet for good glucose management
Physical exercise provides an important balance to maintain good glucose control
Medications ensure adequate insulin activity
Introduce stress coping skills to reduce hormonal imbalance (yoga, meditation)