DiabetesVista Community Clinic and CSUSM Grant

Module 1

Learning Objectives

• Identify the risk factors, diagnosis and prevalence of diabetes in the United States. •Describe the function of the pancreas, the intestines and liver and their role in diabetes.• Identify barriers to effective patient teaching.• Identify and teach to the standards of medical care for the management of Type 2 diabetes.• Identify the importance and the role of medical nutrition therapy in diabetes management.•Understand and teach the role carbohydrate counting and exchange diets in the management of diabetes.

Diabetes Statistics

1994 2010

Problems not just at home

Diabetes statistics

Obesity in Children• Screen: •Overweight: BMI>85 % or weight > 120% of IBW• Plus one other risk factor

•Most common chronic disease in children

Advancing age

Increased prevalence of diabetes

American IndiansHispanics

Non Hispanic blacks

Strong genetic component with environmental influence

Additional Diabetes Risk Factors

•Women who delivered a baby >9 lbs.. or GDM•Hypertension > 140/90• Abnormal labs: HDL cholesterol < 35 mg/dL or triglycerides >250 mg/dL, elevated LDL • Acanthosis nigricans-associated with insulin resistance• Polycystic ovarian syndrome•Microalbuminuria positive • Coronary heart disease

• Acanthosis Nigracans

Which meds can increase the risk of diabetes?

•Oral or injectable corticosteroids decrease glucose uptake. • Thiazide diuretics inhibit insulin release• Statins reduce insulin sensitivity in skeletal muscle, but consider CV benefit• Atypical antipsychotics can cause increase hunger and weight gain•Check FBS on start of these meds and then in 12 weeks to monitor.

Pancreas A&P

• Beta cell granules contain insulin and amylin and these hormones are co-secreted together when nutrients are consumed. • Insulin’s role: Controls post meal blood sugar by:• Promoting the uptake of glucose in the insulin sensitive peripheral tissues.

Insulin Resistance

• /

Insulin resistance at the cellular level

B-cells Combat Insulin Resistance

B cell Exhaustion or pre-programmed?

Liver starts to produce glucose

• Increased hepatic glucose production• Advanced diabetes has less insulin production, less inhibitory effect of insulin on liver glucose

High blood sugar=Hyperglycemia•Most common symptoms: • Excessive thirst •Dry mouth• Increased hunger (especially after eating) • Frequent urination • Fatigue •Unexplained weight loss • Blurred vision•Headaches • Emotional issues, outbursts•Derrer, D. (2014) WebMD

Diabetes affect with body type

Lean patients • Impaired insulin secretion• Insulin resistance less severe

Obese patients• Insulin resistance is severe• Large amounts of insulin in the blood stream initially

Testing for diabetes

• Starts at any age if client is overweight or obese and • One or more additional

risk factors for diabetes

• If no risk factors, testing should begin at 45 years. • If tests are normal repeat every 3 years•Use either the FPG, HA1C or OGTT • Re-test as necessary

How do we diagnose diabetes?• Fasting plasma glucose (FPG)•Diabetes if FPG is > or = 126 mg/dL after no caloric intake for at least 8 hours• OR

•Random plasma glucose • In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis & BS > 200mg/dL

• OGTT Oral glucose tolerance test (OGTT)• Two hour plasma glucose value after 75 gm oral glucose load• Diabetes if the 2 hour PPD is > or = 200mg/dL

•HA1c•Diabetes if > or = 6.5%•More convenient, less day to day changes in BS. •Debated whether to use the same cut points when diagnosing children.

Evaluation tools •Ha1C•Glycation refers to an irreversible CHO-protein linkage•Glucose adheres to a RBC• Based on 120 days, which is the cell life of the RBC•HA1c between 5.7 and ,6.5 is pre-diabetes

Impaired Glucose Tolerance

•Higher than normal blood sugars after a glucose load or meals but not diagnostic for diabetes• 25% go on to develop diabetes

• Impaired glucose tolerance (IGT) using oral glucose tolerance test (OGTT)•Oral glucose tolerance test (OGTT):• 2hour: 140-199mg/dL

Impaired Fasting Glucose

•>100 but <126mg/dL• Identifies persons at high risk for diabetes and CV disease

Health Literacy and Numeracy

• http://professional.diabetes.org/Podcast_Display.aspx?TYP=19&CID=82880&

• Dr. Russell Rothman, ADA Diabetes PRO

• Professional Resources Online

• Assume all patients have limitations on understanding• Patients prefer simplified forms• Avoid jargon•Day to day what do I need to do• Perform “teach-back” technique. Explain a new concept and then ask the patient to explain it back.• Individualized verbal conversation

Current management for Type 2•Diet and exercise•Oral therapy• Insulin therapy

• Type 2 diabetes is a very serious disease with multiple CV factors

Nutritional Therapy Goals

• Balance food with physical activity•Normalize blood pressure•Normalize serum lipid levels• Improved overall health•Maintain body weight•Maintain the pleasure of eating

Which dietary approach?• Thoroughly assess persons food intake and eating habits•Diabetes may be managed with effective dietary and exercise regimen , especially if FPG is < 140.• Pharmacological therapy is often LESS successful if not done with dietary and exercise plan.• Assess progress with BS, HA1c, lipids, blood pressure and weight

Consult a nutritionist

•Nutritional counseling is complex and needs to be individualized.•Nutritionists will:• Conduct initial

assessments• Provide patient education• Develop individualized

meal plans • Provide follow up

Strategies for success• Small change in diet reducing calories•Decrease saturated fat intake• Spread calories throughout the day• Increase physical activity• Psychological support

What is my desired body weight?

•Women:• 100lb. For the first 5 feet, then add 5 pounds for every inch over 5 feet

Men: 106 lb. for first 5 feet, then add 6 lb. for every inch over 5 feet.Add 10% for larger adults, subtract 10% for smaller adults

How many calories is right for me?

•Now take your IBW (ideal body weight) and multiply by 15 for men and physically active woman• IBW multiplied by 13 for most women and sedentary men and adults over 55• IBW multiplied by 10 for sedentary women, obese adults, sedentary adults over age 55• Example: A 5 foot 6 woman that is 58 years old and active.• 100 + 5(6) = 130. 130 x 13 = 1,690 calories/day

Weight Loss• 80-90% of Type 2 diabetes patients are overweight• Improvements seen with only 5 pounds lost:• Improved glucose control• Increased sensitivity to insulin• Improved lipids and blood pressure• Need to lower the doses of meds

•Need 3500 calorie deficit every week to lose 1 pound; 500-1000 calorie decrease/day leads to 1-2 lb. weight loss/week/• Try to eliminate 250-500 calories from diet and increase daily activity by 250-500 calories

Every day recommendations• Even small amounts of weight loss have substantial benefit.• Sugar and starches can be substituted and have similar gycemic reactions.• Fat in the food affects the absorption• Carb counting is used in intensive insulin therapy•When on fixed daily insulin keep your carbs intake consistent

Protein Intake

• Each exchange is 7 grams of protein• Calculating protein intake:• 0.8g/kg of ideal body weight

• 15-20% of daily calories.• Limit to 10% of intake (<0.8 g/kg) in patients with nephropathy.• Severe restriction of protein (0.6g/kg body weight per day) has shown to slow the progression of kidney disease. • Limit high fat meats, whole milk and high fat cheese to reduce lipids and trans fats

Fats: 40-45% of calories

•One fat exchange is 5 grams of fat and 45 calories•Have nutritional value but are very high in calories and contribute weight gain•Mono (olive oil,…) and polyunsaturated fats possibly help heart health•Limit red meat, cheese and whole milk

Fat intake suggestions

•Reduce dietary fat to <30% of the calorie intake•Limit saturated fat to <10% of calories and < 7% of calories in patients with high LDL.•Limit cholesterol consumption to 300mg/day, Increase slightly monosaturated fats, i.e. canola oil and olive oil• In general, one fat exchange is 1 teaspoon of butter, oil and 1 tablespoon of salad dressing.

Carbohydrates • 1 exchange is 15 grams of carb• Fruit exchange is 1 small to med fresh fruit, ½ cup of canned or fruit juice, ¼ cup of dried fruit; 60 calories/exchange• Starch exchanges are 1/2 cup of cereal , grain, pasta, or starchy vegetable, 1 ounce of bread, ¾ to 1 ounce of most snack foods; 80 calories/exchange

40-45% of calories of daily intake •Whole grains• Starchy vegetables• Fruit

• Rate of digestion appears related to presence of fat, ripeness, cooking method, form and preparation.

Sucrose•Modest amounts of sucrose can be substituted for other carbohydrates in the meal plan•Make substitutions using your meter to evaluate the glycemic response . • Sweets contain a lot of sugar and fat, very little nutritive content.• Limit in obesity because of weight gain.

Fructose

• Fruits and vegetables are a natural source of dietary fructose. • Some sweeteners are made from fructose• Contains the same amount of calories as sucrose, even though it is absorbed slower• Can produce adverse effects on serum triglyceride and LDL cholesterol

Sweeteners• Corn syrup, fruit juice concentrate, honey, molasses, dextrose and maltose are similar to sucrose in calories and glucose response• “Sugar free” or “ no sugar added”• Saccharin, aspartame, acesulfame K, sucralose approved by FDA. No calories when used as table top sweetener or in soda…..but need to be worked into food plan when used in baked goods.

• Intense review by the FDA. Tested at levels that equal 21 cans of diet soda/day!•No cancer risk

Food Label with sugar alcohol and carbohydrates•When calculating carbs subtract about ½ of the sugar alcohol.

Alcohol=2 fat exchanges•Moderate alcohol can reduce cardiovascular risk.•Moderate alcohol:• 12 ounce of beer• 5 ounce of wine• 1.5 distilled spirits

•Women one serving, men two servings max• Liver breaks down alcohol and converts to fat. Weight gain. Few nutrients. • Sweet drinks should be avoided• CAUTION: In patients taking sulfonylureas or insulin you may get hypoglycemia. Take alcohol with a meal and perform frequent glucose monitoring

Food Labels

• Review of food labels by Dr. Steve Edelman: • https://www.youtube.com/watch?v=ovD2wVAEFOE

Resources• American Association of Clinical Endocrinologist. (2014). Clinical

Practice Guidelines. https://www.aace.com/publications/guidelines• American Association of Diabetic Educators. (2014). http://

www.diabeteseducator.org/• American

Diabetes Association (2014). Diabetes Pro . Professional Resources Online retrieved from http://professional.diabetes.org/Default.aspx• American Diabetes Association. The Diabetes Advisor retrieved

from associaionthttp://professional.diabetes.org/patientEducationlibrary.aspx?utm_source=dorg&utm_medium=Online&utm_content=printondemand&utm_campaign=pem&s_src=vanity&s_subsrc=dorg• American Diabetes Association (2014). Diabetes Pro. Professional

Resources Online. Podcasts. http://professional.diabetes.org/Adv_SearchResult.aspx?kwd=podcasts&sr=global&ResType=ALL&typ=0&adv=True• Edelman, S., Henry, R. (2011). Diagnosis and Management of Type

2 Diabetes. Professional Communications, Inc.: New York • Joslin Diabetes Center (2015). http://www.joslin.org/index.html• Pagana, K., Pagana, T. (2011). Mosby’s Diagnostic and Laboratory

Test Reference, 10th Edition. Elsevier Mosby:St. Louis, MO.

Resources• Prescriber's Letter (2015). http://prescribersletter.therapeuticresearch.com/home.aspx?cs=&s=PRL&AspxAutoDetectCookieSupport=1•National Diabetes Education Initiative. (2014). http://www.ndei.org/•University California, San Francisco. (2014). Diabetes Education Online. http://dtc.ucsf.edu•Update of the Diabetes and Chronic Kidney Disease. (2012). National Kidney Foundation. https://www.kidney.org/professionals/KDOQI/guidelines_commentaries