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Diabetes Mellitus: Causes and Management

Diabetes mellitus (DM) is a group of metabolic disorders characterized by hyperglycemia and abnormalities in carbohydrate, fat, and protein metabolism. Type 1 DM (5%–10% of cases) usually develops in childhood or early adulthood and results from autoimmune-mediated destruction of pancreatic β-cells, resulting in absolute deficiency of insulin. The autoimmune process is mediated by macrophages and T lymphocytes with autoantibodies to β-cell antigens (eg, islet cell antibody, insulin antibodies).

Diabetes mellitus (DM) is a group of metabolic disorders characterized by hyperglycemia and abnormalities in carbohydrate, fat, and protein metabolism.


Type 2 DM (90% of cases) is characterized by a combination of some degree of insulin resistance and relative insulin deficiency. Insulin resistance is manifested by increased lipolysis and free fatty acid production, increased hepatic glucose production, and decreased skeletal muscle uptake of glucose.

• Uncommon causes of diabetes (1%–2% of cases) include endocrine disorders (eg, acromegaly, Cushing syndrome), gestational diabetes mellitus (GDM), diseases of the exocrine pancreas (eg, pancreatitis), and medications (eg, glucocorticoids, pentamidine, niacin, α-interferon).

• Microvascular complications include retinopathy, neuropathy, and nephropathy. Macrovascular complications include coronary heart disease, stroke, and peripheral vascular disease.

Clinical presentation of type 1 diabetes melitus

• The most common initial symptoms are polyuria, polydipsia, polyphagia, weight loss, and lethargy accompanied by hyperglycemia.

• Individuals are often thin and are prone to develop diabetic ketoacidosis if insulin is withheld or under conditions of severe stress.

• Between 20% and 40% of patients present with diabetic ketoacidosis after several days of polyuria, polydipsia, polyphagia, and weight loss.

Clinical presentation of type 2 diabetes melitus

Patients are often asymptomatic and may be diagnosed secondary to unrelated blood testing.
Lethargy, polyuria, nocturia, and polydipsia can be present. Significant weight loss is less common; more often, patients are overweight or obese.

Diagnosis

Criteria for diagnosis of DM include any one of the following:
 
1. A1C of 6.5% or more
2. Fasting (no caloric intake for at least 8 hours) plasma glucose of 126 mg/dL (7.0 mmol/L) or more
3. Two-hour plasma glucose of 200 mg/dL (11.1 mmol/L) or more during an oral glucose tolerance test (OGTT) using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water
4. Random plasma glucose concentration of 200 mg/dL (11.1 mmol/L) or more with classic symptoms of hyperglycemia or hyperglycemic crisis In the absence of unequivocal hyperglycemia, criteria 1 through 3 should be confirmed by repeat testing.

• Normal fasting plasma glucose (FPG) is less than 100 mg/dL (5.6 mmol/L).

• Impaired fasting glucose (IFG) is FPG 100 to 125 mg/dL (5.6–6.9 mmol/L).

• Impaired glucose tolerance (IGT) is diagnosed when the 2-hour postload sample of OGTT is 140 to 199 mg per dL (7.8–11.0 mmol/L)

• Pregnant women should undergo risk assessment for GDM at first prenatal visit and have glucose testing if at high risk (eg, positive family history, personal history of GDM, marked obesity, or member of a high-risk ethnic group).

Management

Goals of Treatment is to ameliorate symptoms, reduce risk of microvascular and macrovascular complications, reduce mortality, and improve quality of life.

Early treatment with near-normal glycemia reduces risk of microvascular disease complications, but aggressive management of cardiovascular risk factors (ie, smoking cessation, treatment of dyslipidemia, intensive blood pressure [BP] control, and antiplatelet therapy) is needed to reduce macrovascular disease risk.

Appropriate care requires goal setting for glycemia, BP, and lipid levels; regular monitoring for complications; dietary and exercise modifications; appropriate selfmonitoring of blood glucose (SMBG); and laboratory assessment.

Non pharmacological therapy

Medical nutrition therapy is recommended for all patients. For type 1 DM, the focus is on physiologically regulating insulin administration with a balanced diet to achieve and maintain healthy body weight. The meal plan should be moderate in carbohydrates and low in saturated fat, with a focus on balanced meals. Patients with type 2 DM often require caloric restriction to promote weight loss.
 
 


The goals of medical nutrition therapy for diabetes mellitus are to improve overall metabolic outcomes (glucose and lipid levels), provide appropriate energy to maintain desirable body weight, and improve overall health through optimal nutrition. The consistent-carbohydrate meal planning approach incorporates consistent carbohydrate intake, fat intake modifications, and consistent timing of meals and snacks (if needed). The AmericanDiabetes Association recommends the consistent-carbohydrate meal planning approach over the standardized energy-level meal patterns based on the exchange lists.

Indications and Nutrition Diagnosis

Diabetes is diagnosed and classified based on the results of appropriate medical and laboratory tests. After extensive review of the literature and improved standardization of the assay in 2009, the Expert Committee on Diagnosis and Classification of Diabetes Mellitkus has approved the use of the A1C test for diagnosing diabetes mellitus. An A1C test of > 6.5% is the threshold used to diagnose diabetes mellitus

The classification of diabetes mellitus

• Type 1 diabetes (caused by beta-cell destruction that usually leads to absolute insulin deficiency)
 
• Type 2 diabetes (caused by progressive insulin secretory defect on the background of insulin resistance)
 
• Other specific types (due to other causes, e.g., genetic defects in beta-cell function, genetic defects in insulin action, diseases of the exocrine pancreas, or drug or chemical induced)
 
• Gestational diabetes mellitus (diabetesmellitus diagnosed during pregnancy)
The type of diabetes and the individual patient’s needs, as presented by the nutrition signs and symptoms, will determine the nutrition diagnosis, medical nutrition therapy, and approach to self-management training.

The following goals of medical nutrition therapy apply to all persons with diabetes
·        Attain and maintain optimal metabolic outcomes including
a) A blood glucose level in the normal range, or as close to the normal range as safely possible, to reduce the risk of diabetic complications,
b) A lipid and lipoprotein profile that reduces the risk of macrovascular disease, and
c) Blood pressure levels that reduce the risk of vascular disease.
 
•Prevent, treat, or delay the development of obesity, dyslipidemia, cardiovascular disease, hypertension, nephropathy, retinopathy, and neurologic complications associated with diabetes mellitus.
 
•Improve health through healthy food choices and physical activity.
 
•Address individual nutrition needs, taking into consideration the patient’s personal and cultural preferences and willingness to change.
 
•Maintain the pleasure of eating by only limiting food choices when indicated by scientific evidence.
 
•Contribute to normal outcomes of pregnancies for women with preexisting diabetes and gestational diabetes.
 
•Provide adequate energy and nutrients for increased needs during pregnancy and lactation.
 
•Provide adequate energy to maintain normal growth and development rates in children and adolescents with diabetes.

Fiber

According to The American Diabetes Association and evidence-based nutrition practice guidelines fiber consumption recommendations for people with diabetes are the same as for the general population. TheDietary Reference Intake (DRI) recommends consumption of 14 g dietary fiber per 1,000 kcal, or 25 g for adult women and 38 g for adult men. Benefits may occur with intake of 12 to 33 g fiber per day from whole foods or up to 42.5 g fiber day from supplements

Resistant Starch

Resistant starch (non-digestible oligosaccharides and the starch amylase) is not digested and therefore not absorbed as glucose in the small intestine. Legumes are the major food source of resistant starch in the diet; 100 g of cooked legumes contain 2 to 3 g of resistant starch, and 100 g (dry weight) of cornstarch contains about 6 g of resistant starch

Timing of Carbohydrate and Food Intake: Type 1 Diabetes




For individuals requiring insulin, the total carbohydrate content of meals and snacks is the first priority and determines the premeal insulin dosage and postprandial glucose response. The AmericanDiabetes Association recommends that people with type 1 diabetes or pregnant women who take insulin check their blood glucose levels three or more times daily, so that they can adjust food intake, physical activity level, and/or insulin dosage to meet blood glucose goals
 
Intensified insulin therapy (multiple daily injections or insulin pump therapy) 
The goal of intensified insulin therapy is to bring the blood glucose levels as close to the normal range as is feasible for the individual. Insulin infusion pumps mimic the normal physiologic insulin delivery and allow flexibility in meal size and timing. Individuals that use rapid-acting insulin by injection or an insulin pump should adjust their meal and snack insulin doses based on the carbohydrate content of the meals and snacks. 

Patients on multiple-dose insulin (MDI) or insulin pump therapy should do self-monitoring blood glucose (SMBG) at least prior to meals and snacks, occasionally postprandially, at bedtime, prior to exercise. In addition SMBG should be done when a patient suspects low blood glucose, after treating low blood glucose until they are normoglycemic, and prior to critical tasks such as driving.

Adjustments for exercise

Because the amount of physical activity may vary considerably from day to day, individuals with type 1 diabetes may need to make adjustments in energy intake and insulin dosage to avoid hypoglycemia. For individuals on these therapies, added carbohydrate should be ingested if pre-exercise glucose levels are < 100 mg/dL. When exercise is planned, the insulin dose may need to be adjusted to prevent hypoglycemia. Individuals taking sulfonylurea agents have a slightly increased risk of hypoglycemia during exercise, and supplemental energy intake may be required in some cases

Timing of Carbohydrate and Food Intake: Type 2 Diabetes

Treatment with sulfonylureas and other insulin secretagogues also requires consistency in meal timing and the carbohydrate content of meals. People with type 2 diabetes are more resistant to hypoglycemia than people with type 1 diabetes; however, when a person with type 2 diabetes who is treated with insulin or insulin secretagogues is unable to eat, dosages may need to be modified

Delayed meals

When the meal is delayed and the blood glucose level is normal, carbohydrate should be given. Usually 15 g of carbohydrate (one fruit or bread exchange) every 30 to 45 minutes until the meal is served, or 15 to 30 g of carbohydrate for a 1- or 2-hour delay, protects the patient from hypoglycemia.

Enteral nutrition

 For tube feedings, either a standard enteral formula (50% carbohydrate) or a lower-carbohydrate content formula (33% to 40% carbohydrate) may be used. Care should be taken not to overfeed patients because of the risk of exacerbating hyperglycemia

Aerobic exercise can improve insulin sensitivity and glycemic control and may reduce cardiovascular risk factors, contribute to weight loss or maintenance, and improve well-being.



Post a comment

12 Comments

  1. Diabetes is reversible. I am talking about the most common form of diabetes which is type 2.

    I have reversed it in so many cases myself and there are documented cases of thousands of people who have reversed diabetes with the help of experts.

    Glucose is the sugar which is used by every cell of the body to produce energy. This is carried by a hormone insulin to most of the cells. When sugar levels are high, the cells do not allow sugar inside and that is when we say Insulin has become ineffective. i.e. Insulin sensitivity has come down and the condition is known as Diabetes when excess sugar starts to circulate in the blood.

    Even the fat cells no longer store sugar. So any activity which burns energy will make your insulin sensitive and push glucose inside the cells reducing your sugar levels in the blood. When the intake of sugar is reduced, a similar result is observed.

    It takes a long time for the body to reverse diabetes and the body needs a lot of nutrients, as in a diabetic State the body is depleted of many nutrients.

    Diabetics are prone to infection and other chronic diseases like kidney failure, heart disease etc.

    Therefore it is important that you reverse the diabetes with a controlled and customized diet and not by yo yo dieting like reducing food intake. I definitely think that every parent needs to check out the site www.DiabetesReversalTactics.info if you’re serious about reversing your type 2 diabetes.

    Good luck!

    Nabila

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