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

Dietary Management of Type 1 Diabetes

Type 1 diabetes is also known as Insulin-dependent diabetes mellitus (IDDM) or juvenile diabetes. It is a disorder caused by auto immune destruction of pancreatic beta cells resulting in hyperglycemia (elevated blood glucose levels) and with complete absence of insulin. In most cases children and adolescents suffer from this type of diabetes. The treatment involves insulin administration, diet and exercise. It is necessary to maintain adequate nutrition and balanced calorie to meet the growth of a child. The diet is unrestricted except for the avoidance of simple sugars like sugar, jaggery, concentrated sweets, etc.

The goals of dietary management are to aid in normal growth and development, manage blood sugar levels (hypoglycemia and hyperglycemia) and to facilitate healthy eating habits and physical activity to improve metabolic control. Good glycemic control can be maintained only when the child and families learn to balance food, insulin doses and exercise.

The personal preferences and lifestyle habits are taken into account in nutritional care plan. For the children receiving Neutral Protamine Hagedorn (NPH) insulin (twice a day); carbohydrate intake in each meal, timing of meals and physical activity are considered. Children using insulin pumps can be liberal in timing of meal and the amount of carbohydrate ingested.

Type 1 diabetes develops when the beta cells of pancreas that produce insulin are destroyed by the body's immune system. This can also be hereditary, as well as viral infections can lead to this condition.

Following dietary modifications are recommended for this condition:

NUTRIENT	NOTE
Carbohydrate	It is necessary to avoid simple sugars in the child’s diet. The distribution of carbohydrate in the meal of a young child can be- breakfast (20%), mid-morning snack (10%), lunch (10%), evening snack (10%), dinner (30%) and bed time snack (10%). The more the family knows about the maintenance of carbohydrate in the food and the effect of this on the blood glucose levels and the insulin dosage, the more will be the flexibility in the choices of the meals of the child.
Fat	There is an increased risk for cardiovascular diseases for patients with diabetes. Not more than 30% of calories should come from fat and no more than 10% of saturated fat. The normal intake can be 20-25g of fats and oils.
Protein	Protein is required for the growth and development during this stage. Protein should be restricted if there is any renal impairments. Protein rich sources are meat, egg, pulses, poultry, fish, paneer, soya, etc. can otherwise be provided taking into account their fat content.
Fiber	Fiber rich diet helps to reduce the glycemic effect of food. On a nutritional fact label, the grams of fiber are included in the total grams of carbohydrate.
Exercise	Children with diabetes are encouraged to exercise regularly. Families must be taught to monitor blood glucose levels before the exercise and give appropriate snacks based on the blood glucose levels and the type of exercise to prevent hypoglycemia. Carbohydrate should be ingested if the blood glucose level is below 100mg/dL before exercise.

The complications associated with Type 1 Diabetes Mellitus are Hypoglycemia and Hyperglycemia. In hypoglycemia, the blood glucose levels become very low because of not taking meals on time or excess physical activity or high insulin dosage. Hypoglycaemia can cause fainting, sweaty, confused and heart pounding feeling. If not treated, it can cause seizure or can be fatal. In hyperglycemia, the blood glucose level goes higher than the normal levels. It causes more thirst than usual, tiredness and headaches. If not treated, it can lead to other metabolic diseases like renal failure, heart diseases, stroke, blindness, etc.

Foods Allowed	Foods to be avoided
Cereals - Wheat, Jowar, Ragi etc.  Whole grams – Bengal gram, green gram, and dals. Vegetables – Beans, bitter gourd, brinjal, bottle gourd, cauliflower, cabbage, drumstick, ladies finger, onions, garlic, ginger etc. Green leafy vegetables Fruits – Apple, citrus fruits, papaya, Guava, Watermelon, Musk melon, Plum, Pomegranate.	Sugar, jaggery, honey, glucose, sweets etc. Soft drinks, alcoholic drinks, Commercial Beverages. Pastries, cookies, cakes, jams, jellies, ice creams, Maida (refined flour), chocolates etc. Potatoes, yam, sweet potato, banana, grapes, custard apple, chikoo, mangoes and Jackfruit.

A good diet schedule is essential to manage diabetes. Foods should be distributed into five or six small frequent meals rather than three large meals. Fasting and Feasting is not recommended to a Diabetic patient. Intermediary foods like Buttermilk, Tomato juice, Lime juice, Soups and Salads can be taken in-between meals. Fruits should also be taken in-between meals, when the blood sugar in under good control.

Always consult your Doctor or Diabetologist or Dietician before planning diets for your child with Type 1 Diabetes Mellitus.

Post by Divya Konamme