DRAFT: This module has unpublished changes.


Diabetes

 

Definitions


  • Ketone Bodies: By products of fat metabolism used as energy sources for the heart and brain
  • DKA: Diabetic Ketoacidosis is a condition in which the acidity of the blood and urine rises to unsafe levels due to fat breakdown and the resulting buildup of  acidic ketone bodies.
  • Prediabetes: A person at risk of developing diabetes is termed pre-diabetes when their glucose level reach a certain point that is considered at risk but is not yet high enough to be considered diabetes.   

Anatomy/Physiology


List the endocrine and exocrine functions of the pancreas

 

In its endocrine role the pancreas secretes hormones that regulate energy metabolism and fuel homeostasis including glucagon and insulin. Glucagon and insulin maintain normal blood glucose concentrations by facilitating glucose uptake into cells.

As an exocrine function the pancreas helps digest food. The pancreas secretes trypsin, chymotrypsin, and peptidases to breakdown proteins; amylase to breakdown carbohydrates; lipase to break down fats; and nucleases to breakdown DNA and RNA.


Describe the effects of glucagon, epinephrine, growth hormone, corticosteroids and somatostatin on blood glucose levels.

 

Glucagon regulates blood glucose levels. It is released in response to low blood glucose and increases blood glucose. Epinephrine increases blood glucose levels during emergencies and exercise. It responds to sympathetic stimulation during both exercise and stress. Growth hormone promotes growth and increase blood glucose levels during sleep, stress, exercise, and periods of hypoglycemia. Corticosteroids are stimulated during periods of stress to increase blood glucose levels. Somatostatin decreases blood glucose levels by regulating the rate at which food is absorbed from the intestines.

 

Pathophysiology


Discuss the etiology and clinical symptoms of diabetes. Differentiate between Type 1, Type 2 and gestational diabetes.

 

Type 1 diabetes is a disease resulting from autoimmune destruction of the beta cells of the pancreas. It is believed that the autoimmune destruction is related to genetic predispositions and environmental factors. In some cases the cause of Type 1 diabetes is not known. Patients who have Type 1 Diabetes will exhibit fasting hyperglycemia which can be mild or severe and often present with ketoacidosis. Additionally glycosoria, polyuria, and polydipsea also are symptoms of Type 1 Diabetes.

Genetics and heredity may play a role in developing Type 2 Diabetes. There are also several risk factors for Type 2 Diabetes including physical inactivity, poor placental growth, and central body fat distribution. Type 2 diabetics produce insulin but their body cells are resistant to insulin. Type 2 diabetics may experience the same signs and symptoms of Type 1 diabetics but the onset is more gradual. 

 

What is the role of insulin in carbohydrate, protein and fat metabolism? Describe the changes that occur in the metabolism of these nutrients due to diabetes.

 

Insulin helps maintain blood glucose homeostasis by regulating transportation of glucose from the bloodstream into cells to be used for energy. Insulin promotes triglyceride storage via Glut-4 recruitment, inhibits lipolysis, and stimulates fatty acid synthesis in the liver and adipose tissue. Insulin promotes active transport of amino acids from the blood into muscle and other tissues. Patients with diabetes are unable to produce insulin and therefore glucose cannot enter the cells. As a result the cells starve and the body compensates. The body begins to break down fat stored in adipose tissue resulting in lipolysis. The fatty acids produced are converted into keto acids which can be used for energy by muscle and brain cells. Protein catabolism also results.


For each of the following laboratory tests, identify normal values for healthy individuals and the significance of abnormal values in individuals with diabetes.

 

  • Fasting blood glucose: Normal values- 74-106 mg/dL. Blood glucose levels sustained for a long period of time outside of this range have a potential to cause cellular damage.
  • Two hour post prandial blood glucose: Normal -
  • Serum triglycerides: Normal -
  • Serum cholesterol: Normal - < 100 mg/dL. Diabetic patients are at increased risk for developing macrovascular disease. Maintaining cholesterol and triglyceride levels within a normal range is a goal to decrease risk for developing secondary conditions.
  • Urinary glucose: Normal - < 250 mg/dL. Glycosuria usually occurs when the renal threshold for glucose is exceeded. Renal threshold usually occurs at levels higher than 250 mg/dL. 
  • Urinary ketone bodies: Normal – negative. The presence of ketones in the urine shows that there has been breakdown of fat for energy. In diabetic patients this is a risk factor for developing ketoacidosis. 
  • C-Peptide: Normal –.5-3 ng/mL. A C-peptide test can be used to help determine the cause of diabetes and whether a person has type 1 or type 2 diabetes. 
  • Glycosolated Hemoglobin: Normal – 5-7.5% Hb. A high glycosolated hemoglobin demonstrates that blood glucose levels have been high for a long period of time.

Discuss factors which may influence the validity of the GTT.

 

The Glucose Tolerance Test can be affected by a number of different factors including consumption of food (although participants are typically asked to not eat up to 8 hours before the test), exercise, stress, and medications. Therefore the test is only valid in a well controlled environment in which the patient’s medications are known.


Discuss the etiology, symptoms and treatment of insulin reaction (hypoglycemia).

 

A diabetic suffering from an insulin reaction experiences hypoglycemia because he or she does not consume enough food or takes too much insulin or diabetic medications. A person suffering from an insulin reaction may become lethargic, irritable, confused, and ultimately may loose consciousness. If a person’s blood glucose level drops below 70 mg/dL he or she should eat 10 to 15 grams of carbohydrate. This may amount to 3-4 glucose tablets or 4 oz of juice. If a person’s blood glucose level drops below 50 mg/dL they should consume 20 to 30 grams of carbohydrates. Within 15 minutes blood glucose levels should be rechecked and a similar feeding treatment performed again if levels are not above 70 mg/dL.


Discuss the relationship of diabetes to each of the following disorders:

 

Atherosclerosis: Person’s with uncontrolled diabetes tend to have higher levels of Glycated hemoglobin. Glycated hemoglobin may act as a chemical irritant and increase risk of injury to the endothelial lining of the arterial wall resulting in atherosclerosis. 

Nephropathy: High levels of glucose in the blood over time cause damage to the kidneys and ultimately reduce their filtering ability leading to build up of waste products and ultimately kidney failure.

Neuropathy: High blood sugar can damage the body’s nerve fibers.

Retinopathy: High levels of blood glucose can damage the blood vessels that provide blood to the retina eventually causing the lenses to swell and damaging the eyes.

 

Management


For each of the following types of insulin, indicate onset time, peak action time, duration of action and the significance of meal and snack distribution. (Response to this question should be provided in chart format).


Insulin TypeOnset TimePeak ActionDuration of ActionSignificance of meal and snack distribution
Regular30-60 mins2-4 hrs5-8 hrs

Time snacks and meals to be covered by insulin.

Ultralente3-5 hrs8-14 hrs18 hrs

Consume meals and snacks at regular times and with similar levels of carbohydrates.

NPH1-3 hrs8 hrs20 hrs

Consume meals and snacks at regular times and with similar levels of carbohydrates.

Humalog Novalog10-20 mins1-3 hrs3-5 hrs

Time snacks andmeals to be covered by insulin. 

Lantus1 hrNone24 hrs

Consume meals and snacks at regular times and with similar levels of carbohydrates.

Lente1-2.5 hrs7-15 hrs18-24 hrs

Consume meals and snacks at regular times and with similar levels of carbohydrates.

List and discuss factors which affect insulin requirements.


Exercise- blood glucose levels decrease during exercise and insulin is not as readily released by the body 

Smoking- insulin resistance may occur as a result of smoking

Illness- people suffering from an illness often have increased needs for insulin because blood glucose levels are increased by the body

Medication- blood glucose levels may increase or decrease in response to certain medications resulting in an increased or decreased need for insulin

 

When is the use of oral hypoglycemic agents indicated? What adverse side effects are associated with their use? 

 

Oral hypoglycemic agents are indicated in people diagnosed with type 2 diabetes who have not responded to lifestyle changes. There are a number of side effects that can result depending up on the type of oral hypoglycemic agent used, however, hypoglycemia is the most common side effect. Other side effects of oral hypoglycemic agents include nausea, altered levels of specific electrolytes, diarrhea, abdominal discomfort, dry mouth, anorexia, and weight loss or gain among others.

 

State the nutritional goals for patients with diabetes mellitus. Differentiate between Type 1, Type 2 and gestational diabetes. What special considerations must be given to children with diabetes?

 

The goals for people with Type 1 diabetes include: maintaining blood glucose, a lipid profile, and blood pressure within normal ranges; preventing chronic complications; and improving health through healthy eating and physical activity. Goals for people with Type 2 diabetes include adopting a healthy lifestyle through food and physical activity. Blood glucose levels should be monitored and generated information used to determine if changes in eating are necessary. Goals for children should focus on ensuring adequate amounts of energy are provided in order to ensure normal growth and development.


What effect does dietary fiber have on blood glucose levels?

 

Foods high in gums, beta glucans, psyllium, resistant starches, and pectin can lower serum glucose levels by slowing the absorption of glucose from the small intestine. 

 

What is the current recommendation for use of sucrose for patients with diabetes mellitus?

 

Sucrose does not need to be avoided by people with diabetes mellitus. However, the Academy of Nutrition and Dietetics recommends that when sucrose is consumed it should replace other carbohydrates.

 

Discuss the use of sugar substitutes in the diabetic diet. Include in your discussion, safety levels as established by the FDA.

 

Sugar substitutes can be added to food and drinks to add sweetness without adding additional calories because they are thousands of times sweeter than sugar so a smaller amount is needed to obtain similar sweetness.  Sugar substitutes can be used in the diabetic diet when consumed in safe levels as established by the FDA. The FDA has approved five artificial sweeteners including acesulfame potassium, aspartame, saccharin, sucralose, and neotame. Safe levels for these sugar substitutes are as follows: 15 mg/kg acesulfame potassium, 50 mg/kg aspartame, 15 mg/kg saccharin, 5 mg/kg sucralose, and 18 mg/kg neotame.

 

What is the general recommended distribution of macronutrients for patients on diabetic diets? What is the recommended distribution of macronutrients for patients with gestational diabetes?

 

The AMDR for healthy adults is: 45%-65% Carbohydrate, 20-45% fat, and 10-35% protein. The AMDR for diabetic adults is 45% Carbohydrate, 20-45% fat, and 10-35% protein. The AMDR for gestational diabetics is 45% Carbohydrate, 20-45% fat, and 10-35% protein.


Briefly describe the following programs which may be used in planning diabetic meal patterns:

 

  • Exchange list system: Foods within one of three groups including carbohydrates, meat and meat substitutes, and fats can be exchanged or substituted for one another based on the use of a particular list.
  • Glycemic Indexing: Carbohydrate containing foods are based on how they raise blood glucose levels. Foods with high glyemic indexes and low glycemic indexes are then combined.
  • Carbohydrate Counting: Daily carbohydrate consumption is maintained at a stable level and carbohydrates are counted with 15 g of carbohydrate counting as one carbohydrate choice. 

Discuss the challenges of combining diabetic diet restrictions with kosher dietary preferences. Design an appropriate meal pattern, using principles of CHO counting, for a 33 year-old pregnant diabetic patient who is on a 2200 calorie gestational diabetic diet and follows kosher dietary laws.


How might having an eating disorder impact a person with diabetes? 

 

A person with an eating disorder may have disordered eating patterns. Those disordered eating patterns will make it difficult for someone to maintain normal blood glucose levels. Prolonged periods of not eating may cause hypoglycemia and if a person binge eats they may experience hyperglycemia.


There has been an increased incidence of type 2 diabetes in teenagers and children.  What are some of the factors that have contributed to this increase?

 

Some of the factors that have contributed to an increase in the incidence of type 2 diabetes include: decreased levels of physical activity secondary to increased television watching, computer use, and electronic games, increased marketing of calorically dense foods to children, increased access to calorically dense foods including an increased number of fast food restaurants, less physical education programs in schools, and an overall increase in sedentary lifestyle. 

 

Jane is a 24-year-old college senior who was diagnosed as having Type 1 Diabetes at the age of 12. Jane is 5'5" tall and weighs 118 lbs. She takes an injection of 25 units Lantus each evening and 8 units Lispro with each meal.


  • What would be the appropriate diet prescription for Jane?
    1600 kcal - 1900 kcal/day  (30-35kcal/day)
    800 kcal - 950 kcal carohydrates/day (50% carb)
    320 kcal - 380 kcal protein/day (20% carb)
    480 kcal - 570 kcal fat/day (30% fat)
    15 CHO (upper kcal limit at 15 g carbohydrate per CHO)
  • Using the principles of CHO counting, translate this diet prescription into a meal pattern.
    Breakfast: 3 CHO
    Snack: 1 CHO
    Lunch: 4 CHO
    Snack: 1 CHO
    Dinner: 4 CHO
    Dessert: 2 CHO 
  • Using the principles of CHO counting, plan a menu for one day for Jane.
    Breakfast: 1 cup skim milk, 1/2 cup of cereal, 1 banana, 1 boiled egg
    Snack: 1 cup strawberries
    Lunch: 1 chicken tamale, 1 oz cheese, 1/2 cup of black beans, 1 cup raw vegetables, 
    Snack: 1/2 cup carrots, 4 tbsp hummus
    Dinner: 1/3 cup pasta, 1/2 cup of cooked vegetables, 2 oz of fish
    Dessert: 1 cup of ice cream

Mr. D, age 39, is a bank executive who has just been diagnosed as having Type 2 Diabetes. Mr. D is 5'11" tall and weighs 205 lbs. His blood glucose level is 190 mg/dl. Neither insulin nor an oral hypoglycemic agent is ordered.

 

  • What would be the appropriate diet prescription for Mr. D?
    1860 - 2325 kcal/day (20-25kcal/kg)
    930 - 1163 kcal carb/day (50%)
    372 - 465 kcal protein/day (20%)
    558 - 698 kcal fat/day (30%)
    16 CHO
     
  • Using the principles of CHO counting, translate this diet prescription into a meal pattern.
    Breakfast: 3 CHO
    Snack: 1 CHO
    Lunch: 4 CHO
    Snack: 2 CHO
    Dinner: 4 CHO
    Dessert: 2 CHO 
     
  • Using the principles of CHO counting, plan a menu for one day for Mr. D.
    Breakfast: 1 cup skim milk, 1/2 cup of cereal, 1 banana, 1oz sausage
    Snack: 3/4 cup bluberries
    Lunch: 2 slices of bread, 1 oz cheese, 1 oz lunch meat
    Snack: 1/2 cup carrots, 8 dried apricot halves
    Dinner: 1/3 cup rice, 1/2 cup of cooked vegetables, 2 oz of chicken
    Dessert: 2" square of frosted cake 


DRAFT: This module has unpublished changes.

 Click here to view the Diabetes chart review


INTERN’S NAME: Melissa Cannon

INSTITUTION: Cooler-Goldwater

ROTATION AREA: Diabetes

CHARTING TYPE: Not specified 

 

PRECEPTOR’S COMMENTS / CORRECTIONS OF CHARTING

Always use a range for calculating nutrient needs

It is not necessary to state why a patient has decreased appetite

Even if a patient states that he is able to chew appropriately, if a patient complains of loose fitting dentures select that the chewing ability is not appropriate and make a recommendation in the progress note for a dental consult

Limit repetition. During an initial assessment or readmission you should determine specific things including food preferences, food allergies, whether the patient is on Coumadin, and whether the patient is alert and oriented among other things. However, it is not necessary to mention each of these things in the progress note as they are addressed in the assessment form

Many patients have high blood glucose levels and continue to gain weight because they consume food from outside sources. As a result providing education on balancing tray intake with food from outside sources is a common nutrition education topic although compliance tends to be low.


INTERN’S COMMENTS ABOUT NUTRITIONAL INTERVENTION(S):

The patient refused to be switched to a mechanical soft diet. The patient had previously been placed on a modified consistency diet and was worried that the food would not be appetizing. Despite encouragement he still refused to make the change. In addition, the patient had a very high fasting blood glucose level. This was possibly a result of his consumption of outside foods. The patient was educated about the importance of monitoring his blood glucose levels and limiting food from outside sources.


WAS THE NUTRITION INTERVENTION SUCCESSFUL? WHY/WHY NOT?:

The intervention was successful in that the patient’s blood glucose levels were slightly lowered. This may have occurred as a result of switching his diet from regular to medium carbohydrate. However, the intervention was not successful in that the patient continued to obtain food from outside sources and continued to have abnormal spikes in his blood glucose levels. The physician did order a dentistry consult for the patients loose fitting dentures.  

DRAFT: This module has unpublished changes.