Diabetes Flashcards
T2 pathophysiology
Excess body fat and large adipocytes- increased circulating ffas and increased hormones released from adipocytes and inflammation
Insulin resistance in skeletal muscle- impaired ability to stimulate glucose uptake
Insulin resistance in liver- impaired ability to inhibit hepatic glucose output- hyperglycaemia
Pancreatic B cells overworked to increase insulin
Gradually decrease insulin production as B cells gradually fail- hyperinsulinaemia
Short term complications
Hyperglycaemia
Hypoglycaemia if taking insulin or medication
Thirst- importance of kidneys to flush out glucose, increased urination, increased thirst
Long term complications
Microvascular- nephorphathy, eyes, nerves (sensitivity in feet etc), erectile dysfunction
Macrovascular - cv issues, glucose is oxidative, can oxidise LDL causing damage, atherosclerosis
Reduced life expectancy
Monitor
Self monitoring blood glucose
HbA1c - <7%
Lipids tonmonitor risk of microvascular damage
Renal function
Treatment of t2
Newly diagnosed- 3 month trial of lifestyle modification- diet, exercise, smoking cessation
Step 1: monotherapy (metformin)
Step 2: dual therapy
Step 3: add additional oral hypoglycaemia agents or convert to insulin therapy +/- oral agent
MNT for T2
Weight reduction if overweight
Diet that aims to maintain BSL
Management of dyslipidaemia
Nutrition requirements for micronutrients similar to general population, except increased needs for antioxidants
If non insulin requiring:
Weight loss to improve IR
Appropriate medication
Even spread of CHO choice
If insulin requiring
Need to clean strict regular routine of CHO intake (if on mixed insulin), more flexible if MDI (multiple daily injection) with factor of weight loss that pt is likely to comply with
Recommended diets for T2DM
Med diet: can improve HbA1c, may result in weight reduction and improvements in lipids, high in antioxidants
Atkins/ low carb diet; may result in rapid weight loss, controversy about lipid improvements, lower CHO so potentially lower BGL variability
Low fat diet: may result in weight loss
Fasting diet: need to ensure micronutrients are met, take into account medications
Low GI/GL diet: can be affective, CHO amount needs to be considered, can be a confusing concept for some people
Exercise
Can assist in glycaemic control
Can improve blood lipid profile and help maintain healthy body weight
Can improve insulin sensitivity
BSLs should ideally be between 4-8mmol/L
Exercise should not be commenced if BSL >14
May cause metabolic and hormonal changes that can result in hypos or hypers
Hyperglycaemia may occur following exercise and may be prolonged for 12-16 hours post exercise
Insulin adjustment or dietary manipulation may help
Low GI foods may buffer
Hypo management
BGL <4mmol/L
Body releases hormones mainly adrenalin to mobilise glycogen
Symptoms: swelling. Dizziness, confusion, uncoordination, slurred speech, shaking
Treatment:
Confirm with glucometer if possible, 10g rapid acting CHO (3 glucose tablets, 5-6 jelly beans, 209ml juice, 0.5g carb gel, 200ml soft drink) or 2 x sugar sachet in water
Recheck BGL, repeat step 1 if <4.0mmol/L
Follow up with longer acting CHO, ie sandwich, meal of meal time, 5 crackers
Comorbidities and problems
Dislipidaemia Carb counting/ insulin adjustment High A1x Frequent hypos Weight loss Sports nutrition Pre- pregnancy IBS Coeliac disease
MNT for type 1
Carb education:
Broken down into BG
Key to short term BGL control
Need to achieve balance be food eaten and insulin injected to ensure BGL control
Determining amount of carb to be consumed at each meal depends on overall energy requirements, body weight, insulin regime, physical activity and lifestyle patterns
For T1DM, main aim is to match short acting insulin with carb intake usually by varying insulin
Quantifying carbohydrates- exchanges
15g exchanges 1 medium piece of fruit 1 slice of break 1/2 cup cooked rice 2 weetbux 1 small latte with 1 sugar
Useful for people who have a set routine, have had diabetes for a long time, for dietitians and patients quick carb counting, for people taking mixed insulin
Counting carbs in grams
Step 1: identify foods with carbs
Fruit, bread, cereals, lactose goods, sweet foods, starchy veg, legumes
Step 2: weigh and measure amount of food eaten
Look up carb reference values online and calculate how much in portion you ate
If using a recipe count up all high carb amounts and divide by servings- near enough is good enough
GI
Can help BSL/ insulin match as slight delay in leak action of insulin
If meal very low GI or high fat/ protein, may need to adjust insulin
Eg. Pizza can delay gastric emptying and therefor cause a hypo when waiting for digestion
Alcohol
Inhibits glucose production in the liver
Can result in hypoglycaemia, may be delayed by 12 hours post drinking. Test BSLs frequently before bed and on waking up
High consumption can impair self care
Impact after exercise can be higher
High source of calories
No safe amount known
Avoid alcohol with large amounts of added sugar
Drink with meals and consider having a snack
Fat, fibre, protein
Nutrient targets as per general population
Fat, fibre and protein can all lower the GI if a meal
Aim to keep sat fat <10% of energy intake
Encourage lean protein, MUFA and PUFA
Nuts can be convenient snack
High A1C
Insulin: food mismatch, inappropriate diet, not enough insulin
Overeating hypos
Incorrect carb counting
Lifestyle (shifts, exercise, meal patterns)
Fear of hypos
Overnight hypos, check fasting BSL
Maybe a clue if high
Excessive nutrient intake
Insufficient lifestyle changes
Weight gain
Disease progression
Frequent hypos
Look at patterns of BSL Exercise Alcohol Meal skilling Incorrect carb counting Intention/ unintentional weight loss Rule out dietary cause and liase with doctor is you think insulin needs to be adjusted
Coeliac disease
Link between T1DM and coeliac disease
No link with T2DM
Can be more restrictive
Gluten free food- higher GI
Important to try and lower GI by including healthy fat and protein
Carb counting/ insulin adjustment can help
GF hypo food: haribo gummies, GF lollies
Dietetic assessment and intervention important
Focus on relevant micronutrients concurrently
Encourage as wide of a food variety as possible
Gastroparesis
Autonomic nerve damage
Symptoms are measured, vomiting, upper GI pain
Exacerbated by high fat, high fibre, high protein foods
High BSLs delay gastric emptying further
Liquids and solids separately
Liquids may be better tolerated than solids
Assess malnutrition
Higher GI foods may be better tolerated
