Management of Diabetes PG Raman, LC Gupta
INDEX
×
Chapter Notes

Save Clear


Introduction to DiabetesCHAPTER 1

2Diabetes is present when fasting plasma glucose is 126 mg/dL or more on two occasions. When postprandial glucose is over 200 mg/dL.1 Diabetes is estimated to be 57.2 million in our country by 2025,2 while most of these are in 4, 5, 6th decade. But recently number of children and adolescents are coming with type-2 diabetes mellitus. The disease is a major source of disability. Common cause of blindness, chronic renal failure and CAD. There are two main types of diabetes mellitus– Type-1 (insulin dependent) and Type-2 (non-insulin dependent). Type-1 accounts for less than 10 percent of cases. Type-2 diabetes mellitus is around 90 percent. Also known as adult onset diabetes mellitus and patient has insulin resistance. Type-2 diabetes mellitus may need insulin during infection, surgery, ketoacidosis and during complications of diabetes.
In addition to above other types of diabetes mellitus are malnutrition related diabetes, genetic defect of β-cell function and action, secondary diabetes mellitus, drugs and chemical induced diabetes mellitus.
 
 
Classification of Diabetes Mellitus3
  1. Diabetes mellitus
    1. Insulin dependent diabetes mellitus – IDDM, type-1
    2. Non-insulin dependent diabetes mellitus – type-2
    3. Malnutrition related diabetes mellitus
    4. Secondary to pancreatic, hormonal, drug induced, genetic and other abnormalities.
  2. Impaired glucose tolerance.
  3. Gestational diabetes mellitus.3
 
Pathogenesis of Diabetes Mellitus
Type-1
Type-2
Autoimmune
Insulin secretory defect
Genetic 5 percent of siblings 3 percent of parents
Insulin resistance
HLA region on short arm of chromosome
Part of metabolic syndrome
Virus infection rubella, coxsackie, mumps, cytomegalovirus, retrovirus dietary factor, cows milk casein trigger type-1
Obesity
Familial – genetic factor – hereditary factor
 
Complications Directly Linked to Hyperglycemia
Acute
I
Microvascular
II
Macrovascular
III
Diabetic foot
IV
Diabetic ketoacidosis
Diabetic nephropathy
CAD
Neuropathy
Hyperglycemic hyperosmolar non-ketotic coma
Diabetic retinopathy
CVA
Ischemic
Hypoglycemia
Neuropathy
Peripheral arterial disease
Mixed
Lactic acidosis
Infections
 
Management
Three pillars of management of diabetes mellitus are diet, exercise and drugs. With the help of three modalities, blood glucose can be controlled well. Diet is to be followed throughout the life of a diabetic. With slight modification as per age, activity, obesity and presence or absence of complications. No diabetic patient can be treated successfully unless he follows a diet.
Changes in food patterns should be gradual and accordance with the patients and the family members' convenience. Sudden cutting down on calories or fats is rather difficult for patient to follow.4
 
Meal Planning Goals
Type-1
Type-2
Gestational diabetes mellitus
To avoid excessive glycemic swings
To maintain glycemia within normal limits
To maintain blood glucose level within absolute normal
To achieve and maintain normal growth and development
To achieve and maintain normal weight
To achieve normal growth of the fetus and weight gain for mother within limits
To achieve and maintain normal lipid levels
Achieve optimal lipid levels
To maintain normal lipid levels
 
Goals of Glycemic Control in Diabetics
Diets for treating diabetes are to be nutritionally adequate and consist mainly of reduced and spaced intake of carbohydrate foods to lessen the strain on beta cells.
Medical nutrition therapy (MNT) is a term used by the ADA to describe the optimal coordination of caloric intake, with other aspects of diabetes therapy, i.e. insulin, exercise and weight loss. Historically, nutrition impaired restrictive, complicated regimen on the patient. MNT now includes food with sucrose and seeks to modify risk factors like hyperlipidemia and hypertension. MNT must be adjusted to meet the goals of individual patients.
Nutritional recommendations for all persons with diabetes:
  1. Protein should provide 15–20 percent cal per day (10%) for nephropathy.
  2. Saturated fat should provide 10 percent cal/day (<7% for those with elevated LDL).
  3. Polyunsaturated fat to provide 10 percent of cal/day avoid trans unsaturated fatty acids.
  4. 60–70 percent of calories divided between carbohydrates and monosaturated fat.5
  5. Can use caloric sweeteners including sucrose if needed.
  6. 35 gm/day fiber and less than 3000 mg/day sodium are recommended.
Cholesterol intake may be less than 200 mg/d. Alcohol may increase risk for hypoglycemia. Same precautions of alcohol as in general population to be followed. Moderate amount of alcohol with food to avoid hypoglycemia is permitted.
A life style modification program is significantly more effective than metformin prophylaxis in reducing the incidence of type-2 diabetes in high risk subjects. Compared with placebo metformin, reduced the incidence of diabetes mellitus by 31 percent, while lifestyle modification reduced the incidence by 58 percent. Life style modification was highly effective for all ages, all races and most effective in older subjects and subjects with a lower body mass index.4
 
Fat Replacers
Fat mimetics agents belonging to other macronutrient categories are used.
Low caloric fat: Medium chain triglycerides (8 cal/gm)
a.
Caprenin
5 cal/gm
b.
Salatrim
5 cal/gm.
 
Fat Substitutes
 
Side Effects
  • Malabsorption of fat and fat soluble vitamins.
 
Non-absorbable Fats
  • Olestra – sucrose polyester
  • Sorbestrin (hexa fatty acid ester of sorbitol)6
  • Esterified propoxylated glycerol esters (EPGS, - propylene oxide inserted between glycerol and fatty acids). Caloric value of all the fat substitute is ‘0’ zero.
 
Summary of Strengths of Evidence on Lifestyle Factors and Risk of Developing Type-2 Diabetes Mellitus
Evidence
Decreased risk of Increased risk of diabetes mellitus
Increased risk of diabetes mellitus
Convincing
Voluntary weight loss in obese and overweight Physical activity
Overweight and obesity Abdominal obesity Physical inactivity Maternal diabetes mellitus
Probable
Non-starch polysaccharides
Saturated fats IUGR
Possible
n3 fatty acids Low glycemic index foods Exclusive breastfeeding
Total fat intake Transfatty acids
Insufficient
Vitamin E chromium, magnesium, moderate alcohol
Excess alcohol
 
Transfatty Acids its Ill Effects on Body
Trans fat raises LDL and reduces HDL, food cooked in trans fat clogs arteries quicker than food cooked in animal fat based on saturated fat. Trans fat are not easily broken down in the body. Intake of transfat leads to diabetes, metabolic syndrome, obesity and insulin resistance.
REFERENCES
  1. Expert Committee on Diagnosis and Classification of Diabetes Mellitus, Diabetic Care, 1997;20:1183–97.
  1. Ramchandran A, Snehlata C, Latha E, Vijay V, Vishwanathan R. Raising prevalence of NIDDM in urban population in India. Diabetologia 1997;40:232–37.
  1. Park's Textbook of Preventive and Social Medicine, 18th Ed, page 311–13.
  1. Knowler WC. Reduction in type-2 DM with lifestyle intervention. Diabetes Prevention Programme Research Group. NEJM 2002;346–403.