Assessment of nutritional status for diabetic patients

By

Zahraa Esmat Sayed Mahmoud Ali

 

Under Supervision of

Prof.Dr.Mona Khalil Abdel_Kader.Professor of nutrition

Nutrition and Food Science Deprtment.

Faculty of Home Economic.

Helwan University.

 

Prof.Dr.Rawia Rizk Abd El Ghany . Professor of nutrition

Nutrition and Food Science Deprtment.

Faculty of Home Economic.

Helwan University

Diabetes mellitus were described 3000 years ago by the ancient Egyptians. In the 2nd Century AD, Aretaeus gave an excellent description of diabetes.

Thomas Willis in the 17th Century detected the sweet test of urine. Mathew in the 18th Century showed that the sugar in urine comes from the blood.

Introduction

Minkowski and Von Mering discovered that disease of the pancreas is responsible for diabetes to develop in the 19th century.

In the 19th century treatment of

diabetes was confined to food regulation which reduced urination but did not prevent wasting and complications.

They convinced themselves that they had discovered the active pancreatic hormone which normalizes the blood sugar.

The first person to be treated with insulin was Leonard Thompson (1908-1935). The first injection was in 11 January 1922

Definition of diabetes

Diabetes mellitus, often simply referred to as diabetes, it is a group of metabolic diseases in which a person has high blood sugar, either because the body does not produce enough insulin, or because cells do not respond to the insulin that is produced in the body .

Insulin is an endocrine hormone secreted in the body to control the level of sugar; starch and other food are converted into glucose required as energy for daily life.

A pancreas is the gland which secret and releases the insulin hormone; as a result the normal sugar level is maintained in the body. As per WHO guidelines the normal sugar level for a normal person is 60 – 100mg/dl (Before taking any food for the day, hence this value is called Fasting Blood Glucose).

Classifications of diabetes

Commonly known as pre-diabetes refers to a condition in which the fasting blood glucose level is consistently elevated above what is considered normal levels; however, it is not high enough to be diagnosed as diabetes mellitus.

Impaired fasting glucose (IFG):

•It is a pre-diabetic state of hyperglycemia that is associated with insulin resistance and increased risk of cardiovascular pathology.

•IGT may precede type 2 diabetes mellitus by many years. It is also a risk factor for mortality.

Impaired glucose tolerance (IGT):

Type 1 diabetes mellitus is characterized by loss of the insulin producing beta cells of the islets of langerhans in the pancreas leading to insulin deficiency.

Individuals with type 1 diabetes are usually dependent on exogenous insulin and are at risk for ketoacidosis.

Type 1 Diabetes:

It is any degree of glucose intolerance identified during pregnancy and may improve or disappear after delivery.

Gestational Diabetes:

It is caused by insulin resistance with a relative, but not absolute, deficiency of insulin.

The etiology of type 2 diabetes

is uncertain. Individuals with type 2 diabetes

are not prone to ketoacidosis and may be asymptomatic.

It commonly detected after 40

Type 2 Diabetes

Diabetic ketoacidosis (DKA)

Signs and symptoms of diabetes

Complications of diabetes

Diagnosis of diabetes

Treatment of diabetes

Basic educational requirementsThe person with diabetes should acquire adequate knowledge and skills in the following:

Individual therapy targets.Individual nutritional requirements and meal planning.Type and extent of exercise and physical activity.Interaction of food intake and physical activity with oral hypoglycaemic drugs/insulin.Improvements in lifestyle, for example harmful effects of smoking, obesity and alcohol intake.Self-monitoring and significance of results and actions to be takenHow to cope with emergencies (illness, hypoglycaemia)How to avoid complications and detect them at an early stage, e.g. how to take care of the feet.

Monitoring Glycaemic control

Glycaemic control should always be monitored. The absence of symptoms alone should not be taken as an indicator of good control.

Self-monitoring should be encouraged.

Methods and frequency of monitoring depend on the type of treatment, the local facilities available, and therapy targets set.

A number of factors influence glycemic responses to foods, including:

the amount of carbohydrate. type of sugar (glucose, fructose, sucrose, lactose). nature of the starch (amylose, amylopectin, resistant

starch), cooking and food processing (degree of starch gelantinization, particle size, cellular form).

food form, as well as other food components (fat and natural substances that slow digestion—lectins, phytates, tannins, and starch-protein and starch-lipid combinations).

Guidelines for a healthy diet Healthy eating is an important part of your plan to help manage your diabetes.

The list below from the American Diabetes Association offers some healthy eating guidelines:

Fruits and vegetablesMost fruits, like apples, oranges, bananas, and grapes, are fine to eat. Let your health care team know if you have any fruit allergies so they can leave those fruits out of your meal plan. Make sure you eat no starchy vegetables, such as lettuce, spinach, tomatoes, and broccoli.

Whole grainsWhole grains are grains that have not been processed, so they are healthier for you. Choose brown rice or whole wheat pasta as healthier options.

Lean meat These are cuts of meat that contain less fat. When you eat beef or pork, choose cuts that end in “loin,” such as sirloin or tenderloin. When you eat chicken or turkey, remove the skin before cooking.

Fish and seafood Fish and seafood are nutritious and are healthier for you than red meat. Eat them 2 or 3 times a week. Do not eat seafood, however, if you are allergic to it.

DairyChoose skim milk and nonfat or low-fat yogurt and cheese.

Small amounts of saturated fats and cholesterol

When cooking, use liquid oils instead of solid fats like butter, shortening, or lard. If you are trying to lose weight, limit the amount of fat you eat.

Water Drink lots of water—it’s the healthiest thing to

drink when you’re thirsty. If you want a little variety, try calorie-free drinks. Stay away from regular soda, fruit juice, and any other drinks that contain sugar.

Exercise

Increased muscle tone/improved appearance Improved circulation Lowered blood pressure Decreased feelings of stress and tension Lowered level of “bad” (LDL) blood cholesterol Increased level of “good” (HDL) blood cholesterol Decreased blood sugar Decreased risk of osteoporosis Easier weight loss Improved insulin sensitivity.

Some of the benefits of exercise are:

phppPharmacological treatment

Oral Pharmacological Treatment of Type 2 Diabetes

Pharmacological therapy is recommended after 6-12 weeks if an individualized meal plan, activity, and weight loss trial (if needed) have failed to control blood glucose (BG). If the BG remains above 126 mg/dl fasting and over 200 mg/dl 1-2 hours postprandial, pharmacological treatment should be initiated.

There are currently 8 classifications of oral therapy for type 2 diabetes :• Sulfonylureas • Meglitinides • D-Phenylalanine Derivatives • Bile Acid Sequestrant

• Biguanides • Thiazolidinediones • Alpha Glucosidase Inhibitors • DPP-4 Inhibitors

Nutrition assessment

Clinical assessment:

Signs and symptoms of diabetes. Risk factors of cardiovascular diseases, such as smoking,

hypertension, obesity, hyperlipidaemia and family history. Symptoms of cardiovascular complications including angina

and heart failure. Visual symptoms. Symptoms of neuropathic complications such as numbness,

pain, muscle weakness, gastrointestinal symptoms including diarrhoea, impotence and bladder dysfunction.

Drug history. past history Gestational history. Blood pressure

A complete examination is part of the minimum requirements. Certain aspects of the physical examination should receive special attention. These include:

•Height and weight measurements.

•BMI (Body Mass Index).

•Waist circumference.

Anthropometric measurements:

Dietary assessment should include:Diet history.24 hours (recall or record).Food frequency.

Laboratory assessment should include:A blood glucose measurement as a minimum requirement to confirm the diagnosisUrine examination for ketones, protein and glucoseSerum creatinine measurement in all hypertensive patients and those with proteinuriaElectrocardiography and measurement of total serum cholesterol and triglycerides in high-risk individualsHBAIC measurement and quantitative measurement of urine protein as optional investigations that may be performed as part of the initial assessment where facilities and resources allow.

RECOMMENDATIONS

Attain and maintain optimal metabolic outcomes including:

•Blood glucose levels in the normal range or as close to normal as is safely possible to prevent or reduce the risk for complications of diabetes.

•A lipid and lipoprotein profile that reduces the risk for macrovascular disease.

•Blood pressure levels that reduce the risk for vascular disease.

Prevent and treat the chronic complications of diabetes. Modify nutrient intake and lifestyle as appropriate for the prevention and treatment of obesity, dyslipidemia, cardiovascular disease, hypertension, and nephropathy.

Improve health through healthy food choices and physical activity.

Address individual nutritional needs taking into consideration personal and cultural preferences and lifestyle while respecting the individual’s wishes and willingness to change.

Less than 10% of energy intake should be derived from saturated fats. Some individuals (i.e., persons with LDL cholesterol ≥100 mg/dl) may benefit from lowering saturated fat intake to <7% of energy intake .

To lower LDL cholesterol, energy derived from saturated fat can be reduced if weight loss is desirable or replaced with either carbohydrate or monounsaturated fat when weight loss is not a goal.

For persons with diabetes, especially those not in optimal glucose control, the protein requirement may be greater than the Recommended Dietary Allowance, but not greater than usual intake.

Carbohydrate and monounsaturated fat together should provide 60–70% of energy intake. However, the metabolic profile and need for weight loss should be considered when determining the monounsaturated fat content of the diet.

The long-term effects of diets high in protein and low in carbohydrate are unknown. Although such diets may produce short-term weight loss and improved glycemia, it has not been established that weight loss is maintained long-term. The long-term effect of such diets on plasma LDL cholesterol is also a concern.