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Hanadi Baeissa
Disturbance in Glucose Utilization
Diabetes Mellitus- Gestational Diabetes- Impaired Glucose
Tolerance- Hypoglycemia
Hanadi Baeissa
Diabetes Mellitus
There are two types of diabetes mellitus:
Type I, or insulin dependent (IDDM) Type II, or non-insulin dependent
(NIDDM)
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Gestational Diabetes
A temporary type of diabetes that occurs during pregnancy
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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
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The Goals of Diet Therapy for Diabetes1. 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.
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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.
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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
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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
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2. Type 2 diabetes:i. Take diet history usual pattern of
food intake and physical activity ii. Aim to reduce weightiii. Reduce fat intakeiv. Encourage physical activityv. Emphasize the need to control BG,
lipid levels and BP by dietary means, explaining how to do so
vi. Develop an individualized meal plan
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3. Diabetes in Pregnancy:A- Diabetic women who become pregnant:i. Intensive therapy is indicatedii. SMBG must be conductediii. Changing meal plan with advancing
pregnancy to maintain fatal growthiv. Restrict energy intake for obese
women (BMI > 30) v. Encourage physical activityv. Monitor urine for ketones
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B- GDMi. 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
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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
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
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Some Complications of Diabetes
Nutritional Management
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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
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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
Prevention and Management
Avoid precipitating factors Recognize signs Test BG Correct hypoglycaemia If the patient is unconscious glucagon
injections must be given
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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.
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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.B1,B6 and B12 supplement
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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
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Decrease intake of high fiber food Give small frequent meals Chew well Maintain upright posture for 30-60 min
after meal
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Role of the nurse in nutritional management of diabetes
1. Review previous history and diet2. Give positive verbal reinforcement for
any attempt at control3. 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
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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.
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Dietary management of reactive hypoglycemia
1. Limit the intake of simple sugars, and conc. Sweets
2. Emphasize complex carbohydrates3. Eat small frequent meals and snacks (every 2
to 3 hours)4. Include a protein source with meals and
snacks5. Restrict intake of caffeine
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How to approximate the individual dietary needs
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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
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Weight and height
BuildWomenMenChildren
MediumAllow 100 Ib. for first 5 ft. of height, plus 5 Ib. for each additional inch
Allow 106 Ib. for first 5 ft. of height, plus 6 Ib. for each additional inch
Chart growth pattern on graph (Wetzel, Lowa, or Stuart) every 3-6 months
SmallSubtract 10%Subtract 10%
LargeAdd 10%Add 10%
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Determination of caloric needs
For adults1. Basal calories equals desirable body weight
(Ib.) x 10, or (Kgx 22) 2. Add activity caloriesa. 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)
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3. Add calories for indicated weight gain, growth (pregnant women), or lactation
4. Subtract calories for indicated weight loss
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For children1. 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
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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
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
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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
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
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Limitations (modifications for special conditions)
a. Protein
b. Saturated fat and/or cholesterol
c. Sodium
d. Potassium
e. other
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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
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