DIABETES MELLITUS AND THERAPEUTIC NUTRITION DR.

MANALO FEBRUARY 19, 2014

DIABETES MELLITUS
 Represents a primary metabolic abnormality affecting carbohydrates
 Problem in insulin function or problem in insulin absence
 Most common cardiovascular disease that presents an endocrine disorder
 Also involves abnormalities of proteins and fats
 “Hunger in the midst of plenty”
o Too much glucose but you cannot utilize it for energy
o Protein- sparing effect:
 CHO: primary provider of energy
 Fats: next source of energy
 CHON: provides structural and enzymatic function; it does not have to provide energy
BASIC DEFECT
 Lack of insulin: Primary defect (Type I DM)
 Resistance to insulin or lack of insulin receptors: Associated with co-administration of ACE inhibitors; (Type II DM)
 Increase in counterregulatory hormones
o Glucagon
o Steroid hormone
o Catecholamine
o Growth Hormone/ Somatotropin

ABNORMALITIES
 Carbohydrate metabolism
 Protein metabolism
 Fat metabolism
o DKA: represents the most serious dehydration; it affects intracellular, intravascular, and interstitial compartments.
**Treatment: Rapid infusion of IV fluids/ rapid hydration. (2-3 L fluids in the 1st hour)
o HONK
o Without fats, these 2 complications will not occur

PREDISPOSING FACTORS
 Heredity
 Obesity
 Big babies

FASTING BLOOD GLUCOSE

 Non-diabetic: 70-110 mg/dL (6.4mmol)
 Diabetic syndrome: 140 and above (7.7 mmol and above)
 Impaired Glucose Tolerance: in between; must give low dose oral hypoglycaemic agents

INSULIN-DEPENDENT DM NON-INSULIN DEPENDENT DM

Before age 40 ONSET After 40 years

Yes? HEREDITY Yes!

Often lean BODY Often obese

Asthenic HABITUS Hypersthenic

Decreased or none INSULIN Normal to High

Increased, Susceptible GLUCAGON High, Non-susceptible

DKA ACUTE COMPLICATIONS Non-ketotic Hyperosmolar Coma

Insulin, Diet, Exercise TREATMENT INSULIN* (used to initiate treatment, if patient

undergoes surgery, if poor tolerance to OHA)
Oral hypoglycemics, Diet, Exercise

MODY
-Type II DM in patients less than 40 years old

SIGNS AND SYMPTOMS

 Polyuria
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DIABETES MELLITUS AND THERAPEUTIC NUTRITION DR. MANALO FEBRUARY 19, 2014
o Osmotic diuresis
o > 2x at night
o Renal Threshold: 180 mg/dl
 Polydipsia
o Dehydration due to polyuria
 Polyphagia
o Poor hypothalamic control
o Poor glucostatic mechanism
 Pruritus
o If patient has some degree of fungal infection (Candida albicans)
o Especially in females
 Paresthesias
o Because of diabetic neuropathy (most common severe complaint)
o Starts when you begin to sleep

AIMS OF DIETARY MANAGEMENT IN DM (MEMORIZE)

1. Provision of optimum nutrition
2. Achieve ideal body weight
3. Normalize blood sugar
4. Minimize glycosuria
5. Prevent acute complications: DM ketoacidosis
6. Minimize or control chronic complications
o Take ascorbic acid 500 mg 2x a day (prevents cataract)
o When sugar enters the lens, it is converted to sorbitol via 5 alpha reductase which can be inhibited by ascorbic acid
COMPLICATIONS
 Diabetic neuropathy
o Most common
o Least serious
 Diabetic nephropathy
o Most serious
o Determines life span of the individual
o Must not reach 130/80 0r 140/90 for adults
TREATMENT
 DRUGS
o Glucosidase inhibitors (Acarbose)
 Prevent glucose absorption
 SE: Flatulence
o Sulphonylureas
 For the small ones
o Biguanides
 For the large ones
 EXERCISE
o Insulin-like effect
o If athletic, adjust dose to a lower level
 DIET
o Very important for both Types of DM
DIETS IN DM
1. Chemical control
o Prescribes a strict diet that the patient has to adhere to everyday
o Calculated based on IBW
o Uniform all days of the week
o Failure rate is high because of lack of compliance
o Aim: normalizing all blood sugar parameters
2. Clinical Control
o More liberal
o Patient permitted whatever he/she wants for as long as there are no clinical signs or symptoms that would appear
o High compliance rate
3. Intermediate control
o In between chemical and clinical control
o Computed
o Shares advantage of both chemical and clinical control

4 BASIC OBJECTIVES OF DIET CONTROL (MEMORIZE)

1. Treatment of the patient as an individual
2. Provide adequate nutrition with more variety to select from
3. Maintain IBW
4. Keep blood sugar levels at normal or slightly hyperglycemic levels
5. (Optional) Keep urine sugar negative always

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DIABETES MELLITUS AND THERAPEUTIC NUTRITION DR. MANALO FEBRUARY 19, 2014
RENAL THRESHOLD OF GLUCOSE
o 180 mg/dL
RENAL GLYCOSURIA
o Even if patient has blood glucose of 90 mg/dl, he spills glucose into the urine

4 CONDITIONS DIAGNOSED AS DIABETIC COMAS

 DKA: Type I DM
 NKHC/HONK
 Lactic Acidosis
o Complication of Biguanide overdose
 Hypoglycemia
o Only associated with low glucose levels
o Most catastrophic

4 IMPERATIVES OF A DIABETIC DIET (MEMORIZE)

1. Establish regularity of meal pattern
o Most important in Type 1
 Have to coordinate the meal with the insulin administration
2. Compute to achieve and maintain IBW
3. Consider patient’s degree of daily work / activity
o Classify if sedentary, mildly active, moderate active, performs strenuous activity
4. Must be planned with the patient

STEPS IN PRESCRIBING DIABETIC DIET

1. Compute Ideal Body Weight
o Tannhauser’s Formula* (TO BE USED IN THE COMPUTATION)
o IBW = [height (in cm) – 100] – 10%
o Underweight: 10% below IBW
o Overweight: 10% above IBW

2. Compute Basal Caloric Requirement

o BCR= IBW x 24 calories per day
o Rarely would the BCR be above 2,500

3. Compute Total Caloric Requirement (TCR)

o Consider adjustments for:
1. Daily activity +:
1. 25% BCR: Sedentary (CLUE start with christmas day: 25)
2. 30% BCR: Mild
3. 35% BCR: Moderate
4. 40% BCR: Heavy/Strenuous
2. Patient’s present weight
o TCR = BCR + BCR (KA) +/- 500 calories (+500 if underweight; -500 if overweight; none if IBW) ;
**NO MORE +/- if within IBW
** KA: constant (.25/ .30/ .35/ .40)

4. Compute for Carbohydrates, Fats and Protein allowances in calories and grams
o Carbohydrates: 50% TCR (divided by 4 to get grams)
o Proteins: 20% TCR (divided by 4 to get grams)
o Fats: 30% TCR (divided by 9 to get grams)

**Increase intake of fiber in all patients with DM because it will absorb the excess sugar
**No sugar or use sugar substitutes because sugar is vasculotoxic

IMPORTANT ASPECTS OF DIABETIC DIET

 For IDDM: Establish regularity of meal pattern
 For NIDDM: Attain and maintain IBW
o For Type 2 DM, if maintained, sugar control is optimal, no need for medications

SAMPLE PROBLEMS

1. Given: ELM, 27 years old, female with IDDM

Height: 5’2”
Present weight: 41 kgs
Medical intern
IBW
 5’2” = 62 inches (2.54cm/in) = 157.48 cm
 IBW = (157.48cm – 100) – 10% = 57.48 - 5.748
 IBW = 51.732 kg ~~~ 52 kg
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 DIABETES MELLITUS AND THERAPEUTIC NUTRITION DR. MANALO FEBRUARY 19, 2014

 IBW range: 52 kg +/- 10% = 46.8 – 57.2 kg

BCR = 52 x 24 cal/day = 1248 calories/day
Activity : Moderate
TCR = 1248 cal + 1248 cal (35%) + 500 cal
TCR = 2184.8 calories/ day
CHO= 2184.8 cal/day(0.5) = 1092.4 cal/day
= 1092.4 cal/day / 4 = 273.1 grams/day

CHON = 2184.8 cal/day(0.2) = 436.96 cal/day

= 436.96 cal/day / 4 = 109.24 grams/d

Fats = 2184.8 cal/day(0.3) = 655.44 cal/day

= 655.44 cal/day / 9 = 72.82 grams/day

2. Given: Patient Y has NIDDM

Height: 5’4”
Present weight: 77 kgs
Activity: Mild
IBW
 5’4” = 162.56 cm
 IBW = (162.56 – 100) – 10% = 56.304 kg = 56 kg
 IBW range: 56 kg +/- 10% = 50.4 - 61.6 kg
o Overweight
BCR = 56 x 24 cal/day = 1344 calories/day
Activity: Mild
TCR = 1344 cal/day + 1344 (30%) – 500 cal
TCR = 1247.2 calories/day
CHO = 1247.2 cal/day (0.5) = 623.6 cal/day
= 623.6 cal/day / 4 = 155.9 grams/day

CHON = 1247.2 cal/day (0.2) = 249.44 cal/day

= 249.44 cal/day / 4 = 62.39 gm/day
Fats = 1247.2 cal/day (0.3) = 374.16 cal/day
= 374.16 cal/day / 9 = 41.573 grams/day

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