University OF Damanhour Faculty Of Nursing

2nd Year Nutrition course

Dietary management of diabetes mellitus

2012-2013

Dr/ DoaaAbd El SalamAmin

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Outlines :

1. Definitions

2. Classification of DM:

3. S&S of DM type 1&1

4. Assessment finding

5. Risk factors for diabetes mellitus

6. Management of DM

7. Nutritional management

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Glucose is the primary source of energy for the body. It is transported by the blood, and its

entry into the cells is controlled by insulin

Insulin: is a Hormone Secreted by the beta cells of the islets of Langerhans in the pancreas

gland. With each meal, beta cells release insulin to help the body use or store the blood glucose it

gets from food.

Stimulus of insulin: hyperglycemia

Action of insulin: it promotes entry of glucose into the body cells by binding to the insulin

receptor in the cell membrane.

When there is inadequate production of insulin or the body is unable to use the insulin it

produces, glucose cannot enter the cells and it accumulates in the blood, creating hyperglycemia

Diabetes mellitus: is A group of metabolic disease characterizes by elevated levels of

glucose in blood resulting from defect in insulin secretions , insulin action , insulin receptors or

any combination of conditions.

OR it is a Chronic disorder of impaired glucose metabolism , protein and fat metabolism.

In Egypt, the highest incidence of diabetes cases as up to 11 per cent of its population has been

diagnosed with the disease, according to a specialized medical study. It is predicted that the

diabetes cases may double by 2025

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Classification of DM:

Classification

Distinguishing Characteristics’

Type 1 DM

(IDDM)

Affected persons are usually children and young adults, although it can occur at

any age

Dependent on exogenous insulin to prevent ketoacidosis and death.

Type 1 diabetes accounts for 5% to l0% of all diagnosed cases of diabetes.

Type 2 DM

(NIDDM)

Affected persons are often older than 30 year at diagnosis, although it is now

occurring frequently in young adults and children.

The disease is slowly progressive , and treatrnent necessary to control

hyperglycemia varies over time.

Individuals are not dependent on exogenous insulin for survival but often

require it for adequate glycemic control.

Complications of diabetes may be present at diagnosis

Gestational DM Diabetes diagnosed in some women during pregnancy

Other specific

types

Diabetes that results from specific genetic syndromes, surgery drugs,

malnutrition, infections, or other illnesses

Pre-diabetes Fasting or glucose tolerance test results above normal, but not diagnostic of

diabetes( impaired Glucose Tolerance ). These persons should be monitored

closely because they have an increased risk of developing diabetes.

I-Type 1 DM : characterized by destruction of the pancreatic beta cells caused by :

a- Genetic susceptibility

b- Autoimmune response

c- Toxins , unidentified viruses and environmental factors

Signs and symptoms: Classic P ‘s: 1. Polyuria

2. Polydipsia

3. Polyphagia

II-Type 2 DM characterized by insulin resistance and impaired Insulin production.

Signs and symptoms

1. Any of the type 1 symptoms

2. Frequent infections

3. Blurred vision

4. Cuts/bruises that are slow to heal

5. Tingling/numbness in the hands/feet

6. Recurring skin, gum, or bladder infections

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III Gestational Diabetes :

Any degree of glucose intolerance with it is onset during pregnancy

Usually detected between 24-28th

week gestation .Blood glucose return to normal after delivery

of infant .

Assessment finding:

Diagnostic tests: (FBS, RBS HgbA1c, Lipid profile ECG and urine analysis)

HgbA1C : ≥6.5% (it measures average blood glucose levels over several months (120

days). The test measures the percentage of glycated hemoglobin, or A1C, in the blood and

provides an assessment of blood sugar levels over the previous two to three months.

Fasting plasma glucose (FPG) ≥126 mg/dL (7.0 mmol/L) fasting -- for eight

hours -. No caloric intake for at least 8 hours

2-hour plasma glucose test ≥200 mg/dL (11.1 mmol/L) during an OGTT

should be performed as described by the World Health Organization (WHO), (After

fasting for eight hours, a person is given glucose load containing the equivalent of 75 g

anhydrous glucose dissolved in water sugary drink. That person is said to have diabetes if

two hours after the drink he or she has a sugar level higher than 200.) (oral glucose

tolerance or post prandial test )

The Random plasma glucose test: ≥200 mg/dL (11.1 mmol/L), in patients with

classic symptoms of hyperglycemia or hyperglycemic crisis

Risk factor for diabetes :

• Age ↑ - Family History ↑

• Gestational Diabetes ↑ - Obesity / fat distribution (intra-abdominal) ↑

• Physical Activity / fitness ↓ -Smoking ↑

• Very low birth weight ↑ -Depression ↑

• Antipsychotic medications ↑ - Anti-Retrovial therapy ↑

• Dietary Factors

Carbohydrates ↑

Fats ↑

Glycemic load ↑

Cereal fiber / whole grain ↓

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High fructose corn syrup ↑

Sugar-sweetened beverages ↑

Complication of diabetes mellitus:

The long–term effects of diabetes mellitus include progressive development of the

specific complications of:

1. Retinopathy with potential blindness,

2. Nephropathy that may lead to renal failure

3. Neuropathy with risk of foot ulcers, amputation, Charcot joints

4. Features of autonomic dysfunction, including sexual dysfunction.

5. People with diabetes are at increased risk of cardiovascular, peripheral vascular and

cerebrovascular disease.

Short term complication :

Alterations in blood sugars: hyperglycaemia ,hypoglycaemia, and Diabetes ketoacidosis

(DKA)

Also can be categorized : Macro circulations complication (large blood

vessels) and Microcirculation (small blood vessels)

Management of DM

1- Nutritional modification

2- Regular glucose monitoring

3-Drug therapy ( oral and insulin )

4- Client education ( nutritional requirement, exercise, treatment , frequent follow up, foot care

,complication)

Nutritional management :

Goals of nutritional management :

Medical nutrition therapy for people with diabetes should be individualized, with consideration

given to the individual’s usual food and eating habits, metabolic profile, treatment goals, and

desired outcomes. Monitoring of metabolic parameters, including glucose, HbA1c, lipids, blood

pressure, body weight, and renal function, when appropriate, as well as quality of life, is essential

to assess the need for changes in therapy and to ensure successful outcomes. Ongoing nutrition

self-management education and care needs to be available for individuals with diabetes.

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The goals of nutritional management for people with diabetes or pre-diabetes

(those with impaired fasting glycaemia or impaired glucose tolerance) are:

Achievement and maintenance of blood glucose levels and blood pressure levels that is as

close to normal as possible.

Achievement and maintenance of a lipid profile that reduces cardiovascular risk.

Delaying or preventing diabetic complications.

Achievement and maintenance of healthy body weight goals with an emphasis on regular

and consistent physical activity as appropriate.

Addressing individual nutritional needs taking into account personal, maintaining the

pleasure of eating and cultural preferences.

Goals of medical nutrition therapy that apply to specific situations include the

following:

1. For youth with type 1 diabetes, to provide adequate energy to ensure normal growth and

development, integrate insulin regimens into usual eating and physical activity habits.

2. For youth with type 2 diabetes, to facilitate changes in eating and physical activity habits

that reduce insulin resistance and improve metabolic status.

3. For pregnant and lactating women, to provide adequate energy and nutrients needed for

optimal outcomes.

4. For older adults, to provide for the nutritional and psychosocial needs of an aging

individual.

5. For individuals treated with insulin or insulin secretagogues, to provide self-management

education for treatment (and prevention) of hypoglycemia, acute illnesses, and exercise-

related blood glucose problems.

6. For individuals at risk for diabetes, to decrease risk by encouraging physical activity and

promoting food choices that facilitate moderate weight loss or at least prevent weight

gain.

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Dietary recommendation :

Using the assessment data and food and nutrition history information, a preliminary food

and meal plan can then be designed . Developing a food and meal plan does not begin with

a set calorie or macronutrient prescription; instead, it is determined by modifying the

patient's usual food intake as necessary.

General dietary considerations:

Carbohydrates and sweeteners : usually given as 50%-60% of total intake. Foods

containing carbohydrate should be complex, containing high amount from of soluble

fibers and insoluble as whole grains, fruits, vegetables, and low-fat milk should be

included in a healthy diet. High fiber intake appears to reduce the amount of insulin

needed because it lowers blood glucose. It also appears to lower the blood cholesterol and

triglyceride levels.

With regard to the glycemic effects of carbohydrates, the total amount of carbohydrate in

meals or snacks is more important than the source or type.

Sucrose and sucrose-containing foods should be eaten in the context of a healthy diet

Individuals receiving intensive insulin therapy should adjust their pre meal insulin doses

based on the carbohydrate content of meals.

Sweeteners: Nutritive sweeteners, sorbitol and fructose are particularly useful in baking. They

contain as many calories as sucrose and their total intake should not therefore exceed the daily

requirement .

Non-nutritive sweeteners are safe when consumed within the acceptable daily intake

levels established by the Food and Drug Administration (as saccharin, aspartame)

Protein intake accounts for 15–20% of average energy intake, is fairly consistent across

all ages from infancy to older age, and appears to be similar in persons. Derived from

both animal and vegetable sources.

Fat intake: Should be from < 30% of average energy intake in healthy weight and

normal lipid level. The Intake of trans unsaturated fatty acids should be minimized and

saturated fat intake should not exceed 10% of total energy. Cholesterol consumption

should be restricted and limited to 300 mg or less daily. Generally, Total fat intake

should be restricted because diabetic patient have 2-4 times greater risk for IHD

(ischemic heart disease )

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Excessive salt intake is to be avoided. It should be particularly restricted in people with

hypertension and those with nephropathy.

Persons with diabetes should be educated about the importance of consuming adequate

amounts of vitamins and minerals from natural food sources as well as the potential

toxicity of mega doses of vitamin and mineral supplements. Select populations, such as

the elderly, pregnant or lactating women, strict vegetarians, and those on calorie-restricted

diets, may benefit from supplementation with a multivitamin preparation.

General dietary considerations:

Meal planning Assessment of dietary intake.1.

2. Meals and food intake should be planned in relation to economic factors,

availability, cultural and social value.

3. Dietary counseling should be a continuing process to be reinforced during

each visit by all members of the health team.

Consistency of food timing and energy intake from day to day should be 4.

emphasized especially by those taken insulin.

Determination of energy intake is done individually according to age , sex , activity

monitoring height and weight to adjust energy intake

Dietary care plane estimated by the following steps:

A. Calculate ideal body weight = height – 100.

B. Calculate the daily calories requirements= ideal body weight× level of activity.

C. Divided the calories requirement among meals per day.

The total daily caloric requirement should be determined according to activity level:

Activity level Calories requirements

1. Bed rest 25-30 Kcal/kg

2. Light exercise ( house, office) 30-35 Kcal/kg

3. Moderate exercise ( industrial, heavily house work) 35-40 Kcal/kg

4. Heavy exercise (construction work, farm work) 40-45 Kcal/kg

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Composition of diet:

Composition of diet Carbohydrate Proteins Fats

Total calories 50% of total calories 20% of total calories 30% of total calories

1gm CHO give 4

calories

1gm protein give 4 calories 1gm fat give 9

calories

Meal plan:

Meals &

snacks

Calories distributed Composition of diet-

calories

Gram

Breakfast 20% of total calories =

20*total calories /100

CHO=50%of breakfast

Proteins=20% breakfast

Fats = 30% breakfast

CHO gram= CHO calories /

4.

Protein gram= fats calories /

4

Fat gram= proteins calories /

9.

Snack 10% of total calories =

10*total calories /100

Lunch

30% of total calories =

30*total calories /100

CHO=50%of lunch

Proteins = 20% lunch

Fats = 30% lunch

Snack 10% of total calories =

10*total calories /100

Dinner

20% of total calories =

20*total calories /100

CHO=50%of dinner

Proteins = 20% dinner

Fats = 30% dinner

Snack 10% of total calories =

10*total calories /100

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Example :

Weight of diabetic patient was 80 kg and her height was 160 cm she work as

Liberian. Her fasting blood sugar was 200 mg/dL. Calculate the daily caloric

requirement for her.

1-Ideal body weight ( desirable ) = 160 – 100= 60

2-Daily caloric requirement =60× 35= 2100 cal /day

3- breakfast = 2100×20 /100= 420 cal

Amount of CHO. In breakfast = 420 × 50/100 = 210cal

To transfer to gram = 210/4= 52 gm CHO in breakfast and so on for the rest of

meal time ( lunch , dinner , 3 or 2 snacks) and for the rest of macronutrients ( fat

and proteins )

Pathophysiology of diabetes :

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What is the Glycaemic Index?

Different carbohydrate foods have different effects on blood glucose levels.

The Glycaemic Index (GI) ranks food on a scale from 0 - 100 according to the effect they have on

blood glucose levels. Foods with an index number of 70 or more are considered to be high GI,

with an index number between 55-70 as medium GI, and 55 or less as low GI.

Foods with a high GI are those that are rapidly digested and absorbed, resulting in a rapid peak in

blood glucose levels. This is not ideal for people with diabetes, who try to keep their blood

glucose levels fairly stable, without rapid changes in level (peaks or troughs). By contrast, low GI

foods, provided they are also low in fat, are best for controlling diabetes. This is because they

produce a gradual rise in blood glucose and insulin levels because of their slow digestion,

absorption and gradual release of glucose into the bloodstream. This avoids rapid peaks and

troughs.

How can the Glycaemic Index help people with diabetes?

There is evidence that a low GI diet can help control established diabetes, help people to lose

weight and lower blood lipids (fats), and improve the body’s sensitivity to insulin by keeping

blood glucose levels more stable than when high GI foods are consumed.

How do I use the Glycaemic Index?

It’s important to remember that the GI alone should not be your only criteria when selecting what

to eat. The total amount of carbohydrate, the amount and type of fat, and the fibre and salt content

of food are also very important.

Most importantly, you need to watch for fat content as well as the GI. Why? Because foods high

in fat often have a low GI (fat has been shown to slow digestion). However, a high fat diet is not

recommended for overweight people or people with diabetes.

5 simple ways to change to a low GI diet

1. Include one low GI food at each meal

2. Switch to breakfast cereals based on barley, oats (such as porridge), wheat and rice bran

3. Eat grainy breads made with whole seeds, barley and oats, and pumpernickel instead of

white or brown bread

4. Eat pulses and legumes (such as beans, lentils and peas)

5. Eat high fibre foods because it helps slow the digestion and absorption of carbohydrates

For more information on the Glycaemic Index and GI values please refer to the University of

Sydney’s GI website: www.glycemicindex.com

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Both the glycemic index and the glycemic load rankings refer to carbohydrates. When

carbohydrates are digested, sugar enters the bloodstream. The glycemic index ranks how quickly

sugar (glucose) enters the bloodstream after a particular carbohydrate is eaten.

Here is why it is significant:

• If blood sugar rises too quickly, your brain signals your body to secrete a greater amount of

insulin.

• Insulin helps bring sugar out of the bloodstream, primarily by converting the excess sugar into

fat and storing it in your body.

• A greater rate of increase in blood sugar leads to a greater insulin release, more storage of fat

and then a drastic lowering of blood sugar levels. This is what leads to an energy rush followed

by lethargy and hunger after eating a candy bar.

• This is significant because excess insulin secretion can result in various ill health effects such as

fatigue, weight gain and, eventually, type 2 diabetes.

For ranking purposes, the glycemic index is divided into three categories: low, medium and high.

Food is categorized from low to high on a scale of 0 to 100, depending on its effect on blood

sugar levels. Foods that are lowest on the glycemic index have the slowest rate of glucose entry

into the bloodstream, and therefore have the lowest insulin response. The categories are:

• Low (up to 55)

• Medium (56 to 70)

• High (over 70)

Fibre, protein and fat all slow down the entry of glucose from a particular food into the

bloodstream. Most vegetables, beans and whole grains are full of fibre, which is reflected in

their lower glycemic index rating. For example:

• Green peas 48

• All-bran 38

However, processed foods (e.g., white flour) usually contain little to no fibre and therefore tend

to have a higher glycemic index rating. For example:

• Strawberry cupcake 73

• White bread 73

One limitation of the glycemic index is that it does not take into account how much sugar a

particular food contains -- it is only a reflection of how quickly the sugar is absorbed. For

example, the sugar in carrots is readily absorbed into the bloodstream and they are therefore

ranked high on the glycemic index (74). This has given carrots some undeserved bad press. Many

people decide to avoid carrots because they assume that because they are high on the glycemic

index they will cause them to gain weight. This is where the glycemic load of a particular food

becomes very useful.

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The glycemic load takes into account not only how quickly a certain food is converted into sugar

in the body but also how much sugar (carbohydrate) a particular food contains.

The glycemic load categories are:

• Low (10 or less)

• Medium (11 to 19)

• High (20)

Your body's glycemic response depends on both the type of food eaten and the amount of

carbohydrate (sugar) calories consumed. The more concentrated a carbohydrate is, the more

sugar it dumps into your bloodstream. Although all of the sugar that is in the carrots is absorbed

into the bloodstream quickly (high glycemic index), there is not a lot of sugar to begin with (low

glycemic load). As you can imagine, the same amount of dense white pasta would have both a

high glycemic index and a high glycemic load.

This explains why even though carrots are high on the glycemic index, you are not likely to gain

weight eating them

The type of surgery that seems to work is gastric bypass, which shrinks the stomach considerably

and shortens the rest of the digestive system. Studies show the surgery cures diabetes in about 78

percent of patients, usually before weight loss occurs. No one has been sure why, but a hormone

called glucagon-like peptide-1, or GLP-1, has been suspected to play a role for about a decade.

In a person without diabetes, the stomach uses the hormone to warn the pancreas to make insulin

when there is an increase in sugar in the blood.

People with Type 2 diabetes have a defect in how the body responds to and produces insulin in

the pancreas. Increasing GLP-1 levels can help increase insulin production to levels where it can

control blood sugar, and gastric bypass seems to increase GLP-1 production.

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Insulin : physiology

Insulin metabolic functions :

1- Transport and metabolizes glucose

2- Promote Glycogenesis

3- Promotes Glycolysis

4- Enhances lipogenesis

5- Accelerates Proteins synthesis

Pathphysiology : of type 1

Destruction of beta cell ---- decreased insulin production uncontrolled glucose

production by the liver --- hyperglycemia –--- sign and symptoms.

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Pathophysiology : type 2

Decreased sensitivity of insulin receptor to insulin ---- less uptake of glucose ----

hyperglycemia

Decreased insulin production ----- diminished insulin action ---- hyperglycemia --- sign and

symptoms

NB: ( But + ) insulin in small amount ---- prevent breakdown of fats --- DKA is unusual

A1C

• Hemoglobin is a protein on red blood cells that carries oxygen in the blood. When blood

sugar is too high it combines with hemoglobin.

• The more excess glucose in the blood, the higher the percentage of A1C. Healthy adults

without diabetes or prediabetes have an A1C of about 5%. Diabetes patients with very

poorly controlled disease can have levels as high as 25%.

• Under the new recommendations, people with A1C levels between 5.7% and 6.4% will be

considered to have prediabetes and those with levels of 6.5% or higher will be considered

to have diabetes.

Gestational diabetes:

There are two approaches to testing for gestational diabetes:

In the one-step approach, a woman will fast for 4 to 8 hours. Then a health care provider

will measure her blood sugar and will do so again 2 hours after she drinks a sugar

drink. This type of test is called an oral glucose tolerance test.

In the two-step approach, a health care provider measures a woman’s blood sugar 1 hour

after drinking a sugar drink. Women whose blood sugar is normal after 1 hour probably

don’t have gestational diabetes. Women whose blood sugar is high after 1 hour will then

have an oral glucose tolerance test to see if they have gestational diabetes.

Will gestational diabetes affect the baby?

Most women who have gestational diabetes give birth to healthy babies, especially when they

control their blood sugar, eat a healthy diet, exercise, and keep a healthy weight.

In some cases, though, gestational diabetes can affect the pregnancy and baby. Some potential

risks include:

The baby’s body is larger than normal—called macrosomia. A large baby may need to

be delivered by a surgical procedure called cesarean section, instead of naturally through

the vagina.

The baby’s blood sugar is too low—called hypoglycemia. Starting to breastfeed right

away can help get more glucose to the baby. The baby may also need to get glucose

through a tube into his or her blood.

The baby’s skin turns yellowish and the whites of the eyes may change color—called

jaundice. This condition is easily treated and is not serious if treated.

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The baby may have trouble breathing and need oxygen or other help—called Respiratory

Distress Syndrome.

The baby may have low mineral levels in the blood. This problem can causes muscle

twitching or cramping, but can be treated by giving the baby extra minerals

How is gestational diabetes treated?

Many women with gestational diabetes have healthy pregnancies and healthy babies because they

follow a treatment plan from their health care provider.

Each woman should have a specific plan designed just for her needs, but there are some general

ways to stay healthy with gestational diabetes:

Know your blood sugar and keep it under control – By testing how much sugar is in your

blood, it is easier to keep it in a healthy range. Women usually need to test a drop of their

blood several times a day to find out their blood sugar level.

Eat a healthy diet – Your health care provider can make a plan with the best diet for

you. Usually controlling carbohydrates is an important part of a healthy diet for women

with gestational diabetes because carbohydrates affect blood sugar.

Get regular, moderate physical activity – Exercise can help control blood sugar

levels. Your health care provider can tell you the best activities and right amount for you.

Keep a healthy weight – The amount of weight gain that is healthy for you will depend on

how much you weighed before pregnancy. It is important to track your both your overall

weight gain and weekly rate of gain.

Keep daily records of your diet, physical activity, and glucose level – Women with

gestational diabetes should write down their blood sugar numbers, physical activity, and

everything they eat and drink in a daily record book. This can help track how well the

treatment is working and what, if anything, needs to be changed.

Some women with gestational diabetes will also need to take insulin to help manage their

diabetes. The extra insulin can help lower their blood sugar level. Some women might also have

to test their urine to see if they are getting enough glucose.

What happens after the baby is born?

For most women, blood sugar levels go back to normal quickly after the baby is born. Six weeks

after the baby is born, you should have a blood test to check your blood sugar levels. The test

also checks for your risk of getting diabetes in the future.

If you know you want to get pregnant again, have a blood sugar test up to three months before

becoming pregnant to make sure your blood sugar level is normal.

Children whose mothers had gestational diabetes are at higher risk for obesity, abnormal glucose

tolerance, and diabetes.

Women who have had gestational diabetes and children whose mothers had gestational diabetes

are at higher lifetime risk for obesity and type 2 diabetes. It may be possible to prevent type 2

diabetes through lifestyle changes. Talk to your health care provider about diabetes and

increased risk from gestational diabetes.

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In the past, people with diabetes were told to avoid sugar

Now known that complex carbohydrates and sugars have a similar effect on blood

glucose levels

The total amount of carbohydrate is the issue, not just sugar

People with diabetes can have sugar, but the carbohydrate from foods containing sugar

must be worked into the meal plan

Metabolic Actions of Insulin and Glucagon

Fatty acid uptake and

release in fat.

Insulin Stimulates synthesis of triglycerides (TG) from free fatty

acids (FFA); inhibits release of FFA from TG.

Glucagon Stimulates release of FFA from TG.

Liver glycogen

Insulin Increases synthesis and thereby glucose uptake and storage.

Glucagon Stimulates glycogenolysis and glucose release.

Liver gluconeogenesis

Insulin Inhibits, saves amino acids.

Glucagon Stimulates, glucose synthesized and released.

Glucose uptake, skeletal

muscle

Insulin Stimulates uptake, storage as glycogen and use in energy

metabolism.

Glucagon No receptors, no effect.

Glycogen, skeletal muscle

Insulin Stimulates synthesis.

Glucagon No receptors, no effect.

Amino acid uptake

Insulin Stimulates and is necessary for protein synthesis.

Glucagon No receptors, no effect.

Brain (hypothalamus)

Insulin Reduces hunger through hypothalamic regulation.

Glucagon No effect.

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Using Insulin-to-Carb Ratio

Example: 1:10 Ratio

1 unit of insulin to be given per 10 gms carbohydrate eaten

60 gm meal / 10 gms = 6 units of insulin needed

• carbohydrates to consume at meals and snacks

• A general guideline for patients is 45–60 g/meal and 15–30 g/snack

Example Meal Plan:

Meal 225 g 15

Carbohydrate Carbohydrate Choices

Breakfast 45 g 3

Lunch 60 g 4

Snack 15 g 1

Dinner 75 g 5

Evening Snack 30 g 2

Complications of Diabetes

A. Alterations in blood sugars: hyperglycemia and hypoglycemia

B. Macrocirculation (large blood vessels)

• 1. Atherosclerosis occurs more frequently, earlier in diabetics

• 2. Involves coronary, peripheral, and cerebral arteries

C. Microcirculation (small blood vessels)

• 1. Affects basement membrane of small blood vessels and capillaries

• 2. Involves tissues affecting eyes and kidneys

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