MNT 2 - Exam #2 (Part 1) Flashcards
What is the prevalence of DM i the United States?
- 25.8 million Americans have Diabetes;
- 8.3% of population ;
- Type 1 = 5% of all patients with DM;
- Type 2 = 90-95%;
- GDM: (Gestational Diabetes);
- Occurs in 2-10% of pregnancies;
- Have 35-60% chance of developing type 2;
- 7 million undiagnosed;
- Risk for death – DOUBLE → vs. no Diabetes
What is the average cost of DM?
Average. Cost – nearly double due to cost of treatment complications
Who is at risk for developing for DM?
- Age: > 45l
- > 120% IBW; BMI > 25 (especially those with abdominal obesity);
- Have 1st degree relative with dm;
- High risk ethnic group (African-American, Native American, Asian, Pacific Islander..);
- Delivered a baby > 9 lb or dx of GDM;
- HTN (> 140/90 mm Hg);
- HDL < 35 or TG > 250 mg/dl;
- IGT or IFG on previous testing ;
- Habitual physical inactivity
How is DM a diverse group of disorders?
- Differ in origin and severity;
- All share hyperglycemia /glucose intolerance from:
1. defect in insulin production
2. defect in insulin action
3. OR both
What are the 3 types of DM?
-Type 1 DM → Beta cells are destroyed and NO insulin production
-Type 2 DM → Insulin resistance; Cell do NOT RESPOND to insulin and thus glucose builds up and is not taken into cells
-Gestational DM (GDM)
→ IGT and IFG (pre diabetes) = increased risk of DM
What drugs are known to cause DM?
- Diabetes due to other causes (drugs, diseases);
- Corticosteroids put people at a high-risk for development of DM
What are the criteria for Diagnosis of DM?
- Symptoms of DM plus casual blood glucose of > 200 mg/dL
OR - Fasting plasma glucose > 126 mg/dL
OR - 2-hour post-load glucose > 200 mg/dL during an OGTT
OR - HgbA1c > 6.5
What are the diagnostic criteria for IFG and IGT?
- IGT – Impaired Glucose Tolerance
- IFG – Impaired Fasting Glucose
— IFG = FPG > 110 and < 126 mg/dL
— IGT = 2 hPG > 140 and < 200 mg/dL
Who are the members of the medical treatment teams for patients with DM?
- Physicians, Nurse Practitioners, PA’s;
- RD/ DTR;
- CDE (Nurse &/or RD);
- Pharmacists;
- Mental Health Professionals;
- Other “allied health professionals”
What is the key to treatment with DM and preventing complications?
Diabetes Care, the EARLIER, the BETTER = Early Screening → Early Diagnosis → Early Care → Delay/Prevent Complications
What is included in the Lifetime Management of DM?
Includes “4 M’s”:
- MNT
- Physical activity
- Blood glucose monitoring
- Medications
- Self-management education (DSME)
What are the goals of MNT for DM?
- *An overall good and healthful diet it applicable to DM and CVD and Renal Disease! All are one in the same with small variations;
1. Achieve and maintain optimal BG (blood glucose), BP (blood pressure), and lipid levels
2. Improve overall health (diet and exercise)
3. Address individual energy and nutrients needs while considering personal/cultural preferences, lifestyle, and patient’s readiness to change → Plan should be practical!
4. Prevent or delay, and treat long-term complications of DM:
What is included in the Education on Complication of DM?
- Long term = Myopathy, Neuropathy, Retinopathy, Nephropathy, CVD
— Retinopathy is one of the most prevalent FIRST signs - Acute = Hyper- and Hypoglycemia
What does the AND says about Macronutrient recommendation for DM?
- “RD’s should encourage consumption of macronutrients based on the DRI’s for healthy eating as research does not support any ideal percentage of energy from macronutrients for persons with diabetes.” JADA. 2010:119:1852-1899.;
- No ONE diabetic diet → There is a lot of variation depending upon the patient ;
- Focus is NOT on the TYPE of CHO, but on the distribution and timing of the CHOs throughout the day
What are the recommendations for CHO?
- Total CHO vs Source of CHO
- Sucrose vs other CHO’s
- Dietary fiber: per dietary guidelines
- Emphasis on balanced diet
- Non-nutritive sweeteners are safe → Do produce a lower postprandial response and have lower energy values
What are the recommendations of Protein?
-Usual protein intake of approximately 15-20% energy can be maintained
-Exceptions for CHANGE =
•Individuals with excessive protein choices that are high in saturated fat content
•Individuals with protein intake < RDI’s
•Patients with diabetic nephropathy
What are the recommendations for fat?
- Cardio-protective nutrition interventions;
- If LDL level is > 100, use TLC
1. DM = risk equivalent=previous CVD/no DM
2. <7% saturated fat and 200 mg/d cholesterol
3. Limit intake of trans- fatty acids
What are the recommendations for Micronutrients?
- NO CLEAR evidence of benefit from vitamin or mineral supplementation
- EXCEPTIONS:
- Folate (prevent of birth defects) → Follow standard recommendations;
- Calcium (prevent bone disease) → Follow standard recommendations;
- Routine supplementation with antioxidants is NOT advised;
- Due to the uncertainties related to long-term safety
What are the Acute Complications or “Sick Days” with DM?
- Hypoglycemia
- Hyperglycemia
- DKA
- HHNS → Hyperosmolar Hyperglycemic Non-Ketotic Syndrome
What is Hypoglycemia?
Signs and symptoms = Initial S/S
— Neuroglycopenic S/S (inadequate glu to brain: confusion, irrational bx, seizure, coma);
— Test BG if possible/ if not – treat → CHECK
What is the treatment for Hypoglycemia?
— Treatment: → TREAT = initial 15-20 g of glucose
— Best thing is glucose tablets → Straight dextrose (w/o any extra calories)
— Re check in 15 minutes/ re treat if necessary → RE-CHECK
— Glucose levels will begin to fall after ~ 60 minutes of the glucose consumption
— Reevaluate/ additional tx if needed / consider a snack with CHO & protein
— IF next meal is more than about an hour away recommended a snack
What are ways to prevent and some of the causes?
Prevention/ causes?
- Too much meds
- Skipping or delayed meals → Recommend packing snacks or meals if busy!
What is Hyperglycemia?
ELEVATED blood glucose - Increase thirst – Polydipsia - Frequent urination – POLYURIA → Increased fluid loss - Weight Loss → Particularly with Type 1 - Blurry Vision - Delayed wound healing - Irritability and hunger - Fatigue
What are the causes of Hyperglycemia?
- Excessive food/ CHO intake
- Over-treatment of hypoglycemia
-Wrong timing of DM medications
— Insulin must be injected so that it peaks at the SAME time the blood glucose peaks from the meal that is consumed
— Some are taken at meals, some at bedtime → All depends on patient and medication - Illness → Sometimes meds have to be increased during illness due to increased stress and elevated blood glucose during sickness
-Stress → Raises blood glucose - Gastroparesis/other affecting digestion or absorption
- Physical Activity
- Other medications
What are the treatments and prevention methods of HYPERglycemia?
- Insulin Injections
- Oral-medications → Can take up to 3 different oral meds
- Diet
- Exercise
- Stress Management
- Treating subsequent illnesses
What are Acute Illness/Sick day management?
- Medications = continued/ may be increase;
- Monitor BG(before meals and snacks);
- Monitor Ketones (especially for T1DM);
- Adequate fluids;
- Adequate CHO;
- Watch for DKA;
Adequate CHO for Sick Day Management
-Prevent starvation ketosis!
-Adults= 150-200 g/CHO daily Or 45-50gm CHO every 3-4 hrs. Or 10-15gm CHO every 1-2 hrs. (may use liquids/ provide list of easy to tolerate CHO food/ beverages)
— 4oz. Regular Ginger-Ale
— 4oz. Apple Juice
What are the symptoms of DKA?
- Moderate to large amount of urine ketones, severe N/V diarrhea/ abdominal pain, rapid breathing, fruity breath;
- Kussmal Respirations = Rapid Breathing
What are the differences in HHS and DKA?
- *DKA and HHNS are the most ACUTE and short-term complications of DM;
- Blood glucose does NOT get as high with DKA, as HHNS → BOTH are caused by HIGH glucose (lack of insulin causing alternate pathway of ketone formation)
What are the long term MICRO and MACROVASCULAR complications of DM?
1. Microvascular complications → “opathies” — Nephropathy — Retinopathy — Neuropathy (Peripheral and Autonomic) 2. Macrovascular complications → CVD
What is Nephropathy?
(Microvascular); - Single leading cause of CKD - Marker for nephropathy and CVD: microalbuminuria 30-299 mg/24hr; -Progress to macroalbuminuria -Protein “restriction” and ACE inhibitors -Need to monitor for long-term damage -Optimal glycemic control -BP guidelines per JNC8: —JNC8 = 140/90 — American Diabetes Association = 130/80
What is Retinopathy?
(Microvascular);
- Most frequent cause of new blindness;
- Associated with duration of DM, though often dx with retinopathy first;
- Likely if nephropathy present;
- Macular edema: hypertension contributes;
- Glaucoma & cataracts- occur earlier in patients with DM;
- Cataracts can occur substantially earlier in life with DM;
- Progression slowed with glycemic and BP control
What is Neuropathy?
(Microvascular);
-Neuropathy = 60-70% of patients with DM;
What is Peripheral Neuropathy?
- Peripheral neuropathy → Loss of nerve function; Begins as tingling in the hands and mostly in the feet and eventually turns to significant pain and total loss of feeling;
- Prevention – Have patients were supportive, well-fitting shoes and socks at all times;
What is Autonomic Neuropathy?
→ Autonomic Nervous System;
1. GI tract: gastroparesis (slow gastric emptying and peristalsis) → from damage to VAGUS nerve;
— Constipation/diarrhea, anorexia, N/V, early satiety, persistent bloating = Slow emptying can lead to increased appetite but lack of absorption and utilization;
- Dietary treatment = Low fiber, Low fat, Small meals throughout the day;
3.Genitourinary tract
Sexual dysfunction = Recurrent UTI’s, injury to kidneys, incontinence;
- Cardiovascular system
— Resting tachycardia (>100bpm)
— Orthostatic hypotension – decreased blood pressure upon standing up or extreme changes of position
— Increased risk silent heart disease
What are the CVD Macrovascular complications?
- 65% of deaths;
- Elevated glucose = endothelial damage to blood vessel (causes the initial injury to the blood vessels) ;
- Thickening and changes in composition of sub-endothelial layer;
- Decreased flexibility of vessels;
- Coexistence of hypertension & dyslipidemia = Very linked and must all be managed;
- Underlying metabolic syndrome;
- Treat hypertension and lipids → Start with the blood glucose – start with 3-4 initial visits and then recommend RD visits every 6 months
What do damages to the large blood vessels lead to…..
- Increased risk of stroke;
- High blood pressure and increased risk of heart attack;
- Blocked arteties in legs;
- Reduced blood flow to the feet causing sores that heal slowly or not at all — Infections are common due to high blood glucose levels that favor microbial growth — can cause amputations of the feet and toes
What do damages to the small blood vessels lead to….
- Bleeding in the retina leading to blindness;
- Damage to kidney cells; Excretion of protein in the urine and eventually kidney failure;
- Nerve damage that causes numbness and pain;
- Nerve damage causing numbness and tingling in the feet that affects balance and increase risk of accidental injury
How are long-term complications prevented?
-INTENSIVE THERAPY reduced risk of retinopathy by 77% =
— Slowed progression by 54%
— Reduced the occurrence of microalbuminuria by 32%
— Reduced the occurrence of micraalbuminuria by 47%
*Major focus on managing BG
What studies contributed to the benefit of intensive therapy?
- Studies in early 1990’s
1. DCCT
2. UKPDS - Dramatically changed how we approach treatment of Diabetes
What are the group goals for specific groups?
- Children and adolescents → Normal growth and development rates
- Pregnancy → Provide adequate needs and nutrients for positive outcomes
- Elderly → Provide adequate needs and nutrients for aging
What are the Food Composition Databases?
- Nutrient Database for Standard Reference developed by the USDA Agricultural Research Service;
- International Nutrient Databank Directory (July 5, 2013) = The source for this databank is the USDA Nutrient Database for Standard Reference
- Food and Nutrition Database for Dietary Studies = Describes the dietary information collected in US studies
What are other databases that might be utilized in nutrition research?
- Special-interest databases = Agricultural Research Service has databases for added sugars, choline, flavonoids, fluoride, isoflavones, oxalic acid and proanthocyanidins
- Dietary supplements databases
= Developed by the National Center for Health Statistics; - Food contaminants databases = Still in the development phase
What are the features of these databases?
“Give an accurate and appropriate name for each food item and provide sufficiently descriptive terms to distinguish each food from all other foods in the database”
- Food Grouping
- Unit or weight
