diabetes%20mellitus
DIABETES MELLITUS
Diabetes mellitus (DM) is a heterogenous metabolic disorder characterized by the presence of hyperglycemia with carbohydrate, protein and fat metabolism disturbance which results from defects in either insulin secretion or action.
Patients with DM usually present with polyuria, polydipsia and unexplained weight loss.
Type 1 DM is caused by beta cell destruction which leads to complete insulin deficiency. It may be immune mediated or idiopathic.
Patients may present with ketoacidosis or acute onset of hyperglycemia while other patients may resemble type 2 DM or symptoms of other autoimmune disorders.
Type 2 DM is the most common form of diabetes. It is secondary to defect in insulin secretion concomitant with insulin resistance.
Majority of patients are asymptomatic. Ketoacidosis is uncommon and is usually secondary to stress (eg infection).

Patient Education

  • Patients with pre-diabetes should be informed of their increased diabetes mellitus and cardiovascular disease risk, and should be counseled about effective ways to lower their risk
    • Interventions and follow-up should be most vigilant in patients with HbA1c >6%, who are considered to be at very high risk for developing diabetes
    • Annual monitoring for the development of diabetes mellitus is advised

Diabetes Self-Management Education (DSME)

  • A skills-based approach focusing on how to help patients with diabetes to make informed self-management choices
  • An unending process that incorporates the needs, goals and life experiences of patients with diabetes mellitus which facilitates knowledge, skill and ability that they need for self-care
  • Given to patients with diabetes according to national standards at the time of diagnosis and later as needed
  • Helps patients with diabetes to initiate useful self-management and cope with diabetes mellitus as soon as they are diagnosed
  • Aids patient to optimize metabolic control, prevent and manage complications, and maximize quality of life in a cost-effective way
  • Includes medical nutrition therapy, physical activities, sufficient sleep, preventing smoking, limiting alcohol consumption and reducing stress on psychosocial issues
  • Key results are effective self-management and quality of life
  • Studies have shown that diabetes self-management education improved diabetes knowledge and self-care behavior, improved clinical results (eg lower HbA1c), reduced weight, and improved quality of life at lower cost
  • It has been found that better A1c reduction is achieved when there is more contact time between the patient with diabetes mellitus and the educator

Lifestyle Modification

Medical Nutrition Therapy (MNT)

  • Focuses on how to improve metabolic outcomes of diabetes mellitus by modifying nutrient intake and lifestyle
  • Important in preventing and managing hyperglycemia and delaying diabetic complications
  • In patients with pre-diabetes, medical nutrition therapy may help lower diabetes mellitus and cardiovascular  disease risk by promoting healthy food choices and physical activity which will lead to moderate weight loss that is sustained
  • In patients with diabetes mellitus, medical nutrition therapy will help reach and maintain blood glucose, blood pressure and lipid profile levels as close to normal
    • Deals with individual nutritional needs based on personal and cultural preferences, severity of disease, and patient’s readiness for change
    • Maintains eating pleasure by only restricting food choices that are necessary for metabolic control
  • In patients with diabetes mellitus treated with Insulin or insulin secretagogues, medical nutrition therapy provides self-management training for safe performance of exercise, preventing and treating hypoglycemia, and managing acute hyperglycemia
  • Adjustment of insulin dose should match carbohydrate intake with specific reference to sucrose-containing or high glycemic index food
  • Studies had shown that after 3-6 months of medical nutrition therapy, HbA1c is decreased by 1% in type 1 diabetes mellitus and 1-2% in type 2 diabetes mellitus and LDL-C reduced by 15-25 mg/dL/0.4-0.6 mmol/L
  • There is no recommendation on nutrition that can prevent type 1 diabetes mellitus

Diet

  • The cornerstone of diabetes mellitus management
  • Advise patients to avoid missing meals and it should be synchronized with time actions of the medication
  • Balanced diet is recommended which consists of 50-60% energy from carbohydrate, 15-20% from protein and 25-30% from fats
    • Individualized based on glucose and lipid targets
    • For digestible carbohydrate, the recommended dietary allowance (RDA) is 130 g/day and is based on providing adequate glucose
    • Lower fat intake, especially saturated fat, may decrease diabetes mellitus risk by producing an energy-dependent improvement in insulin resistance and promoting weight loss

Calories

  • Total calories (amount/day) must be calculated based on patient’s needs
  • Studies suggest that for patients with diabetes, there is no ideal percentage of calories from carbohydrates, protein and fat
    • Macronutrient distribution should be individualized based on metabolic goals, current eating patterns and preferences

Carbohydrate

  • Amount and type of carbohydrate ingested determine the postprandial response
  • Should be obtained from fruits, vegetables, whole grains, legumes and low-fat milk
  • Glycemic index (GI) may be used in guiding choices of food and provides benefit in altering postprandial response
    • It is a measure to classify type of carbohydrate based on its effect on the blood glucose level
    • Food with high glycemic index value raises blood glucose more rapidly than food with medium or low glycemic index
  • Total intake of carbohydrate should be consistent and equally distributed throughout the day
    • Monitor total daily intake of carbohydrate to achieve glycemic control
  • Should match carbohydrate content of meal to doses of Insulin and insulin secretagogues
  • Resistant-starch/high-amylose foods
    • Eg legumes, raw potato, formulated cornstarch
    • May alter postprandial glycemic response, prevent hypoglycemia and decrease hyperglycemia; however, no long-term studies have shown benefit from using resistant-starch in patients with diabetes mellitus
  • Sweeteners
    • Sucrose can be used in replacement to other carbohydrate sources in meal plan
    • Sucrose intake is counted as part of the total carbohydrate intake; excess intake may cause weight gain
    • Naturally occurring fructose in fruits, vegetables and other foods may be used which only accounts for 3-4% of energy intake
    • Artificial sweeteners (eg acesulfame K, aspartame, neotame, saccharin, sucralose) and sugar alcohols (eg erythritol, isomalt, lactitol, maltitol, mannitol, sorbitol, isomalt, xylitol, tagatose, hydrogenated starch hydrolysates) may be used within daily intake levels
      • Sugar alcohols have lower available energy (2 cal/g) and produce a lower postprandial glucose response than sucrose or glucose
      • Sugar alcohols lower the risk of having dental caries but have no evidence in decreasing blood sugar, energy intake, or weight
 Fiber
  • Because of the general health benefits of fiber, diabetes mellitus patients are encouraged to increase intake to 14 g fiber/1000 kcal/day or approximately 38 g/day for men and 25 g/day for women
  • 5-7 servings or 20-30 g of fiber/day is recommended
    • Eg vegetables, fruits, legumes, whole grain products and fiber-rich cereals (≥5 g fiber/serving)
    • Dietary fiber and whole grain-containing foods are associated with better insulin sensitivity and ability to secrete insulin sufficiently to overcome insulin resistance

Dietary Fat and Cholesterol

  • There is a lack of evidence to recommend an ideal amount of total fat intake for patients with diabetes
  • As recommended for the general public, an increase in foods rich in n-3 linolenic acid and long-chain n-3 fatty acids (EPA, DHA) is also recommended to patients with diabetes
  • In type 2 diabetes mellitus patients, a Mediterranean-style, monounsaturated fatty acid (MUFA)-rich diet may be recommended as an effective alternative to a higher carbohydrate, lower-fat eating pattern since these may benefit cardiovascular disease risk factor and glycemic control
  • In type 2 diabetes mellitus, the recommended amount of dietary saturated fat, trans fat and cholesterol is the same as that for the general public

Protein

  • Good-quality protein (eg meat, poultry, fish, eggs, milk, cheese, soy) has high protein digestibility-corrected amino acid scoring pattern (PD-CAAS) scores and supplies all 9 indispensable amino acids
  • Should not be used for the treatment of acute or for the prevention of nocturnal hypoglycemia since protein increases insulin response without increasing plasma glucose concentrations

Alcohol

  • Limit to ≤1 drink/day for women and  ≤2 drinks/day for men to reduce diabetes mellitus, coronary heart disease and stroke risk
    • 1 alcohol-containing beverage is defined as 12 oz beer, 5 oz wine or 1.5 oz distilled spirits which contains 15 g of alcohol
    • All types of alcohol-containing beverage have similar effects
  • In patients using Insulin or insulin secretagogues, alcohol should be consumed with food to lower risk of nocturnal hypoglycemia
  • May increase blood glucose level when taken with carbohydrate

Micronutrient

  • There is insufficient evidence of benefit from mineral or vitamin supplementation in patients with diabetes who do not have underlying deficiencies

Sodium

  • Na intake should be limited to <2300 mg/day as per recommendation to the general public
    • Should avoid foods high in sodium (eg soy sauce or other sauces, pre-mixed cooking paste, preserved and processed foods) and salt in cooking should be limited to ¼-½ teaspoonful/day
  • For patients with both hypertension and diabetes, further reduction in sodium intake should be individualized

Physical Activity

  • Regular exercise improves blood glucose control, lowers cardiovascular disease risk factors, contributes to weight loss, decreases the risk of falls and fractures, improves quality of life by improving functional capacity and sense of well-being and prevents the development of type 2 diabetes mellitus in individuals who are at high risk
    • At least 8 weeks of exercise intervention has shown 0.66% reduction in HbA1c in patient with type 2 diabetes mellitus
  • It is recommended that patients with diabetes have at least 150 minutes/week of moderate-intensity exercise spread over at least 3 days/week with no >2 days consecutive days without exercise
    • Twice weekly resistance training, if without contraindications, is recommended
  • Vigorous activity is not recommended in patients with ketosis
    • Can worsen hyperglycemia of patients with diabetes mellitus type 1 who have not received Insulin for 12-48 hours and are ketotic 
  • Carbohydrate should be given to patients using Insulin or insulin secretagogues if pre-exercise glucose levels are <5.6 mmol/L (<100 mg/dL)
    • Physical activity can cause hypoglycemia if medication dose or carbohydrate consumption is not adjusted in patients taking Insulin or insulin secretagogues
  • Should assess patient for certain exercises that might be contraindicated to their condition (ie uncontrolled hypertension, severe autonomic neuropathy, history of foot lesions, unstable proliferative retinopathy)
    • High-risk patients should be advised to start with low-intensity exercise at short periods and then slowly increase the intensity and duration
    • Vigorous aerobic or resistance exercise should be avoided by patients with proliferative or severe nonproliferative diabetic retinopathy due to possible risk of vitreous hemorrhage or retinal detachment
    • Proper footwear should be advised in all patients with peripheral neuropathy, and those patients with foot injury should be restricted to nonweight-bearing activities
    • Cardiac investigation should be done in patients with diabetic autonomic neuropathy before starting any intense physical activity since autonomic neuropathy is strongly associated with cardiovascular disease in diabetic patients
    • There are no exercise restrictions in patients with diabetic kidney disease but they should be reminded that physical activity can acutely increase urinary protein excretion
  • Moderate-intensity and vigorous exercise may improve insulin sensitivity and reduce risk for type 2 diabetes mellitus
  • Recent evidence have shown that by breaking bouts of sedentary activity by briefly standing or walking every 30 minutes may help prevent type 2 diabetes mellitus for those who are at risk and may aid in the glycemic control in those with diabetes mellitus

Weight Management

  • A 5-10% weight loss from initial body weight over a 6-month period is advised in all individuals who are overweight or obese who have or are at risk of diabetes mellitus which can be achieved by a lower calorie intake (20-25 kcal/kg body weight), lower dietary fat intake, at least 150 minutes/week physical activity and behavioral modification
    • In Asians, waist circumference ≥31 inches in women and ≥35 inches in men, and BMI >23 kg/m2 are at high risk for type 2 diabetes mellitus and cardiovascular disease
    • Moderate weight loss leads to decreased insulin resistance, improved blood sugar and lipid levels, and lower blood pressure
    • Either low-carbohydrate or low-fat calorie restricted or Mediterranean diets may be helpful in losing weight for up to 2 years
    • Lipid profiles, renal function, and protein intake should be monitored in patients on low-carbohydrate diet, and anti-hyperglycemic therapy must be adjusted
    • Weight loss medications may be advised in overweight or obese patients with type 2 diabetes mellitus
      • Please see Obesity Disease Management Chart for more details
    • In patients with type 2 diabetes mellitus and BMI ≥35 kg/m2, bariatric surgery may be considered which can result in obvious improvements in blood sugar
Sleep
  • All patients should be advised to sleep approximately 7 hours per night to maintain energy levels and well-being
  • It showed in some evidence that 6-9 hours sleep per night reduces cardiometabolic risk factors
    • It was also found that sleep deprivation causes insulin resistance, hypertension and dyslipidemia aggravation and increase in inflammatory cytokines
Behavioral Support
  • Patients with diabetes mellitus is encouraged to join community groups that promote healthy lifestyle for emotional support and motivation
  • There are high rates of obesity, anxiety and depression in patients with diabetes mellitus that can adversely affect outcomes
  • Cognitive behavioral therapy was found to be beneficial
Smoking Cessation
  • For patients having difficulty with smoking cessation, nicotine replacement therapy should be considered
  • For more recalcitrant patients that cannot stop smoking on their own, structured programs are recommended
  • It has been found that smoking may have a role in the development of type 2 diabetes mellitus


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