Type 2 Diabetes

progressive disease that, in many cases, is present long before it is diagnosed. It is commonly referred to as Diabetes and is known be caused among Adults. Hyperglycemia (High glucose levels in Blood) develops gradually and is often not severe enough in the early stages for the person to notice any of the classic symptoms of diabetes. The primary defect in type 2 diabetes is insulin resistance, a reduced sensitivity to insulin in muscle, adipose, and liver cells. To compensate, the pancreas secretes larger amounts of insulin, and plasma insulin concentrations can rise to abnormally high levels (hyperinsulinemia). Over time, the pancreas becomes less able to compensate for the cells’ reduced sensitivity to insulin, and hyperglycemia worsens. The high demand for insulin can eventually exhaust the beta cells of the pancreas and lead to impaired insulin secretion and reduced plasma insulin concentrations. Type 2 Diabetes is therefore associated with both insulin resistance and relative insulin deficiency; that is, the amount of insulin is insufficient to compensate for its diminished effect in the cells.

The various risk factors for type 2 diabetes mellitus include genetic and environmental factors including a family history of diabetes, older age, obesity (particularly intra- abdominal obesity), physical inactivity, a prior history of gestational diabetes, pre-diabetes and ethnicity.

The various symptoms associated with this condition are:

Polyurea	Excessive urine output especially at night
Polydypsia	Excess thirst due to loss of water (polyuria)
Polyphagia	Increased appetite, urge for sweet items due to heavy loss of sugar in urine
Loss of weight	failure of glucose and protein utilization by the body and tendency towards polyphagia
Pruritis Vulva	Irritation in genitalia caused by local deposition of sugar from urine. Causes disturbed sleep.
Paraesthesia	Tingling sensation felt on hands and feet, due to loss of body protein.
Blurring of vision	Excess glucose deposits on the eye lens causing refraction changes resulting in blurring of vision
Delayed wound healing & minor infections	Lack of nutrients on the wound delays healing. Minor recurrent infection occurs (boils, foot, skin, urinary infection, gangrene)

Ketosis is a condition which begins with insufficient insulin to meet body’s needs. Several factors that work together include illness, infection, injury or emotional stress thereby increasing body’s need for insulin. Ineffectiveness of insulin leads to release of energy from liver glycogen and fat stores. Omitting insulin doses, reducing exercise thereby upset the food, insulin and energy balance. These factors increase the tendency towards aggravating ketoacidosis. Onset of ketoacidosis is gradual but in young diabetics this development is rapid. Diabetic coma can develop within 12-24 hours. Most symptoms resemble hypoglycemia but additional symptoms can appear. Excessive urination, excessive thirst, increased hunger, drowsiness, unexplained weight loss, slow healing of cuts and wounds, dry itching skin, vaginal itching, abdominal pain and rapid shallow breathing with acetone smell.

Ketoacidosis can be prevented by maintaining near to normal blood glucose level and testing for presence of ketone in blood and urine if any of the following exist:

·         Blood glucose level >240mg/dl

·         Fever is present

·         Nausea and vomiting

·         Stress

·         If insulin dosages are being adjusted 

Type 2 Diabetes Mellitus is diagnosed by the following methods:

• Oral glucose tolerance test: Used to identify new or at-risk individuals, Carried out after 12 hours of fasting, 75g (1.75g/kg body weight) of glucose dissolved in a glass of water is given to the person to ingest. Fasting and two hours after glucose load blood samples are taken.

Diagnostic criteria for IGT and Diabetes
Parameter	Blood Sugar levels (mg/dl)
	IGT	Diabetes
Fasting	<120	>120
Glucose load 2 hours after (PP)	120-180	>180

• Urinary sugar test (Benedicts test): Normally no glucose is excreted in urine. In diabetics, glucose is excreted by kidneys when sugar levels >180mg/dl. Called Renal threshold. Amount in urine depends on severity and CHO intake. Not reliable test as lactose (in lactating women) also reduces to give positive result. Uristix -dipped in urine and colour change indicates sugar level.

Interpretation of Benedict’s test
Colour	Report	Urine g%	Blood mg%
Green discoluration	0- trace	-	<200
Green ppt	+	0.25	200-250
Greenish yellow ppt	NA	0.5	250-300
Yellow orange ppt	+++	1.0	300-350
Brick red ppt	++++	>2.0	>350

• Glycosylated Hemoglobin test (HbA1 C): HbAl C assay is now highly standardized and is a reliable measure of chronic glucose levels. The Al C test reflects longer-term glucose concentrations and is assessed from the results of glycosylated hemoglobin (simplified as A1C) tests. When hemoglobin and other proteins are exposed to glucose, the glucose becomes attached to the protein in a slow, nonenzymatic, and concentration-dependent fashion. Measurements of AIC therefore reflect a weighted average of plasma glucose concentration over the preceding weeks. In nondiabetic persons AIC values are 4% to 6%; these values correspond to mean blood glucose levels of approximately 70 to 126 mg/dl, (3.9 to 7 mmol/L).

Nutritional management can both improve blood glucose levels and slow the progression of diabetes complications. Personal preferences and lifestyle has to be considered for the care plan.

Medical nutrition therapy requires an individualized approach and effective nutrition self-management education and counseling. Monitoring glucose, HbA1C and lipid levels, blood pressure, weight, and quality-of-life issues is essential in evaluating the success of nutrition-related recommendations.

The amount of carbohydrate ingested has the greatest influence on blood glucose levels after meals—the more grams of carbohydrate ingested, the greater the glycemic response. The carbohydrate recommendation is based in part on the person’s metabolic needs (that is, the type of diabetes or degree of glucose tolerance) and individual preferences. The carbohydrate intake must be fairly consistent at meals and snacks to help reduce fluctuations in blood glucose levels between meals. 60-65% of the total calorie needs can be a carbohydrate recommendation. The carbohydrate content of the food must be of complex carbohydrates. Simple carbohydrates like sugars and refined flour should be avoided. Low-carbohydrate diets, which restrict carbohydrate intake to less than 130 grams per day, are not recommended.

It is necessary to maintain adequate amounts of protein to maintain normal body composition and prevent depletion of lean tissue mass. 1 g per kg body weight of protein is recommended for an adult diabetic without complication. In case of renal complications protein intake should be restricted according to the clinical parameters.

People with diabetes are at high risk of developing cardiovascular diseases. Guidelines for dietary fat are similar to those for other persons at risk, saturated fat intake should be limited to less than 7 percent, polyunsaturated should be 10 percent, monounsaturated fat should be 20 percent of total calories and trans fat intake should be minimized, and cholesterol intake should be limited to less than 200 milligrams daily.

Vitamins and minerals are required to maintain the normal body functioning. Magnesium depletion is associated with insulin insensitivity. Sodium restriction is good for the people with hypertension and diabetes.

Fiber rich diet helps not only to lower the blood glucose levels (by delaying the absorption from the intestine) but also helps in lowering the cholesterol levels. Fiber rich diet also helps in controlling the calorie content of the food. 25 g of fiber per 1000 KCal of food per day is the recommendation.

Image Courtesy: Krause Food & Nutrition Care Process

Post by Divya Konamme