Management of Diabetis Mellitus
Definition
Classification
The general classification of diabetes is based upon two major types:
a) type I, insulin-dependent diabetes mellitus (IDDM); and
b) type II, non-insulin-dependent diabetes mellitus (NIDDM).
Eighty-five to ninety percent of the diabetic population is non-insulin
dependent; the other 10 to 15 percent is insulin-dependent.
Type1- Insulin Dependent Diabetes Mellitus
What is it?- This is the most severe form of diabetes, occurring most often in childhood or
young adulthood. The body attacks the beta cells in your pancreas so no more insulin is
produced. Glucose is still produced from carbohydrate metabolism but instead of entering
cells, it builds up in the blood. T1D may, or may not, be an inherited trait.
Causes- Recent research indicates that the islet cells of the pancreas may have been
damaged, either by a disease (such as rubella) or by certain chemicals that were toxic,
which led to the onset of the disease.
Symptoms- The classic symptoms of IDDM are polydipsia, polyphagia, and polyuria,
accompanied by rapid weight loss and often ketoacidosis.
Importance of dietary management- IDDM has a rapid onset, is very unstable, and
causes metabolic imbalances that are difficult to control. For these reasons the diet is very
carefully planned and coordinated with the insulin and exercise regime.
Failure of management- Failure to time and regulate the meals with these factors will
result in great fluctuations in blood glucose, ranging from acute hypoglycemia to extreme
hyperglycemia.
Type 2- Non Insulin Dependent Diabetes Mellitus
What is it?- Type 2 diabetes, formerly called ‘adult-onset diabetes’ or ‘non-insulin- dependent
diabetes’, is the most common type of diabetes. The onset of type 2 diabetes can be at any age –
even during childhood – and is mainly caused by obesity.
Causes- Type 2 diabetes usually begins with insulin resistance, a condition in which fat, muscle
and liver cells do not use insulin properly. Obesity, physical inactivity, and hypertension are
strong risk factors for the onset of NIDDM.
Symptoms- The symptoms are similar to those of IDDM, except there is no weight loss and very
rarely ketoacidosis.
Management strategies- NIDDM is a milder form of diabetes and is most often controlled with
weight loss and an exercise program. Occasionally an oral hypoglycemic drug will be necessary.
Failure of management - diabetic persons have increased risks of developing major
complications such as kidney disease, vascular disease, nerve impairment, and diseases of the
retina of the eye. In fact, as much as 20% of the diabetic population becomes blind. Fluctuations
of blood glucose from uncontrolled diabetes are thought to be one important factor in the onset
of these conditions, making it even more imperative to manage and monitor the diet carefully.
Diagnosis of diabetes and prediabetes
Classic symptoms such as polydipsia, polyuria, and rapid weight loss associated with
gross and unequivocal elevation of blood glucose (over 11.1 mmol/L, or 200 mg/dL)
make the diagnosis of diabetes mellitus.
A fasting plasma glucose level above 7.0 mmol/L (126 mg/dL)
Hyperglycemia that is not sufficient to meet the diagnostic criteria for diabetes is
classified as either impaired fasting glucose (IFG) or impaired glucose tolerance (IGT).
IFG and IGT have been officially termed “pre-diabetes”
IFG = fasting plasma glucose (FPG) 100 mg/dL (5.6 mmol/L) to 125 mg/dL (6.9
mmol/L)
IGT = 2-h plasma glucose 140 mg/dL (7.8 mmol/L) to 199 mg/dL (11.0 mmol/L)
An oral glucose tolerance test (OGTT) can be performed for impaired fasting plasma
glucose (6.1–7.0 mmol/L, 110–126 mg/dL), when 2-hour postprandial plasma glucose
exceeds 7.8 mmol/L (140 mg/dL) or for individuals at high risk of diabetes
The OGTT identifies individuals with diabetes, impaired glucose
tolerance, and gestational diabetes.
After an overnight fast of 10 to 16 hours, an oral glucose load of 75
g (or 40 g/m2) is given. The subject remains seated during the test.
Water is permitted, but smoking is not. Blood is taken before glucose
administration and 0.5, 1, 1.5, and 2 hours later for plasma glucose
determination
Acute complications of diabetes
Diabetic Ketoacidosis (DKA)
DKA is a common and life-threatening complication of type 1 diabetes, particularly at the time of diagnosis.
In type 2 diabetes patients, DKA occurs during concomitant acute illness or during transition to insulin dependency
DKA is caused by very low levels of effective circulating insulin and a concomitant increase in glucagon, cortisol,
and growth hormone. Impaired glucose utilization and increased glucose production by the liver and kidneys result
in hyperglycemia. Lipolysis leads to increased production of ketones, especially beta-hydroxybutyrate (β-OHB),
ketonemia, and metabolic acidosis which is exaggerated by ongoing fluid and electrolyte losses.
Insulin omission, inadequate insulin dosing during infection, gastrointestinal illness, trauma and stress, or pump
failure can precipitate DKA
DKA is defined as a triad of:
hyperglycemia, i.e., plasma glucose >250 mg/dL (>13.88 mmol/L)
• venous pH <7.3 and/or bicarbonate <15 mmol/L
• moderate or large ketone levels in urine or blood
Treatment: correcting dehydration, correcting electrolyte imbalance, continuous IV insulin adminstration
HYPERGLYCEMIC HYPEROSMOLAR STATE (HHS)
HHS is defined as extreme elevation in blood glucose >600 mg/dL (>33.30 mmol/L) in the absence of
significant ketosis and acidosis.
Decrease in the effective action of circulating insulin coupled with a concomitant elevation of counter
regulatory hormones lead to increased hepatic and renal glucose production and impaired glucose
utilization in peripheral tissues, which result in hyperglycemia and parallel changes in osmolality of the
extracellular space.
HHS is associated with glycosuria, leading to osmotic diuresis, with loss of water, sodium, potassium,
and other electrolytes.
The majority of HHS episodes are precipitated by an infectious process; other precipitants include
cerebrovascular accident, alcohol abuse, pancreatitis, myocardial infarction, trauma, and drugs
Treatment: diabetes education, prevent dehydration by intravenous rehydration, avoid medications such
as corticosteroids, intravenous insulin to correct hyperglycemia
HYPOGLYCEMIA
The goal of treatment of hypoglycemia is to immediately increase the blood glucose
approximately 3–4 mmol/L (~55–70 mg/dL). This can be accomplished by giving glucose
tablets or sweetened fluids, such as juice, glucagon injection in unconscious patients, or
dextrose infusion in a hospital setting
Medical Nutrition therapy
Characteristics and goals
Goals of nutrition therapy
Medical nutritional therapy is pivotal in the management and care of diabetes. Nutritional
intervention provides a cost-effective strategy for reducing the complications, hence the
morbidity and mortality, of diabetes.
The The first and preeminent goal is achieving and maintaining blood glucose levels
as near normal as possible by balancing food intake with insulin (either endogenous
or exogenous) or antidiabetes agents. Prevent hyperglycemia and hypoglycemia
Second in priority is achieving and maintaining optimal serum lipid levels.
Cardiovascular disease is the most common complication of diabetes. Lipoprotein
abnormalities play a major role in atherosclerosis.
regulate safe levels of fatty acids, ketones, and amino acids by optimizing glucose
use, normalizing glucose production, and enhancing insulin sensitivity
Nutrition therapy for type 1 DM
Usual food intake and pattern preference should be determined and used as the basis
for insulin requirement prescriptions
Eating at consistent times is vital for appropriate use of insulin.
Intensified therapy may be considered for those willing and able to comply and can
provide considerably more flexibility in meal planning.
Individuals can be taught to adjust premeal insulin to compensate for changes in their
meal plans, to delay premeal insulin for meals that are late, and to administer insulin
for snacks that are not part of their meal plan.
Intensified therapy may include carbohydrate counting with adjusted multiple
injections or use of an insulin pump. The individual's skill and educational level must
be considered.
Nutritional Therapy for Type II Diabetes
Emphasis should be placed on maintenance of desired weight and glucose, lipid, and
blood pressure goals. Loss of 10% of current weight was shown to improve diabetes
control
Strategies may be aimed at improving food selection (e.g. reducing dietary fats and
saturated fats), spreading meals throughout the day, and incorporating regular exercise
habits.
If dietary and behavioral intervention is not successful, an antidiabetes agent may be
needed.
Stopping or changing oral agents is preferable to dietary manipulation for type 2 diabetic
patients who are experiencing hypoglycemia.
Insulin therapy should be a last resort after all combinations of oral medications have been
exhausted, as it may exacerbate concomitant hyperinsulinemia and promote weight gain.
Nutritional plan
Exercise
The following are the types of insulin available
in the market:
