Diet Pada Penyakit DM

Nutrition and Diabetes
Mellitus
Chapter Sections and Learning Objectives (LOs)
20.1 Overview of Diabetes Mellitus

LO 20.1 Characterize type 1 and type 2 diabetes and discuss the complications
associated with these conditions.
20.2 Treatment of Diabetes Mellitus

LO 20.2 Explain how diabetes can be managed using dietary adjustments,
medications, and physical activity.
20.3 Diabetes Management in Pregnancy

LO 20.3 Describe the possible e ects o diabetes on pregnancy outcomes
and the approaches used to maintain glycemic control in pregnant women with
diabetes.
20.4 Nutrition in Practice: Metabolic Syndrome

LO 20.4 Identi y the eatures and possible consequences o the metabolic
syndrome and describe the current treatment approaches or this condition.
chapter
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20
The incidence of diabeTes melliTus is sTeadily increasing in The
United States and many other countries. It now affects an estimated 12.2 percent of
adults aged 18 and older in the United States, or about 30 million people.1 About
24 percent of persons with diabetes are unaware that they have it,2 a danger because
its damaging effects often occur before symptoms develop. Diabetes ranks seventh
among the leading causes of death in the United States. It also contributes to the
development of other life-threatening diseases, including heart disease and kidney
failure, which are discussed in the two chapters that follow.
t (DYE-ah-BEE-teez) t :
a group o metabolic disorders
characterized by hyperglycemia and
disordered insulin metabolism.
20.1 Overview of Diabetes Mellitus
diabetes 5 siphon (in Greek), The term t t refers to metabolic disorders characterized by elevated blood
re erring to the excessive passage glucose concentrations and disordered metabolism. People with diabetes may
o urine that is characteristic o be unable to produce sufficient insulin or use insulin effectively, or they may have both
untreated diabetes types of abnormalities. These impairments result in defective glucose uptake and utili-
mellitus 5 sweet, honeylike zation in muscle and adipose cells and unrestrained glucose production in the liver. The
: a pancreatic hormone that result is , a marked elevation in blood glucose levels that can ultimately
regulates glucose metabolism; its cause damage to blood vessels, nerves, and tissues. Box 20-1 defines diabetes-related
actions are countered mainly by the symptoms and complications.
hormone glucagon.
t : the blood
concentration o a substance that Symptoms of Diabetes Mellitus
exceeds the kidneys’ capacity or Symptoms of diabetes are usually related to the degree of hyperglycemia present (see
reabsorption, causing the substance Table 20-1 and Box 20-2). When the plasma glucose concentration rises above about
to be passed into the urine.
200 milligrams per deciliter (mg/dL), it exceeds the t , the concentration
Bo 20-1 Glossary of Diabetes-Related Symptoms and Complications

t t : a distinctive fruity odor on the breath of a person plasma glucose levels between 100 and 125 mg/dL suggest
with ketosis. prediabetes; values of 126 mg/dL and above suggest diabetes.
: the presence of albumin (a blood protein) in the : a condition of extreme
urine, a sign of diabetic nephropathy. hyperglycemia associated with dehydration, hyperosmolar blood,
t (CLAW-dih-KAY-shun): pain in the legs while walking; and altered mental status; sometimes called the hyperosmolar
usually due to an inadequate supply of blood to muscles. hyperglycemic nonketotic state.
t : a coma that occurs in uncontrolled diabetes; may : abnormally low blood glucose concentrations.
be due to diabetic ketoacidosis, the hyperosmolar hyperglycemic In diabetes, hypoglycemia is treated when plasma glucose falls
syndrome, or severe hypoglycemia. Diabetic coma was a below 70 mg/dL.
frequent cause of death before insulin was routinely used to k t (KEY-toe-ass-ih-DOE-sis): an acidosis (lowering of blood
manage diabetes. pH) that results from the excessive production of ketone bodies.
t t (neh-FRAH-pah-thee): kidney damage that k t (KEY-toe-NOOR-ee-ah): the presence of ketone bodies in
results from long-term diabetes. the urine.
t t (nur-RAH-pah-thee): nerve damage that results k t (key-TOE-sis): elevated levels of ketone bodies in body
from long-term diabetes. tissues.
t t t (REH-tih-NAH-pah-thee): retinal damage that t : disorders that affect large blood
results from long-term diabetes. vessels, including the coronary arteries and arteries of the limbs.
: death of tissue due to a deficient blood supply and/or t : disorders that affect small blood
infection. vessels, including those in the retina and kidneys.
t (GAS-troe-pah-REE-sis): delayed stomach emptying, : a condition characterized by impaired
often caused by nerve damage in a person with diabetes. blood circulation in the limbs.
(GLY-co-SOOR-ee-ah): the presence of glucose in the urine. (POL-ee-DIP-see-ah): excessive thirst.
: elevated blood glucose concentrations. Normal (POL-ee-FAY-jee-ah): excessive hunger or food intake.
fasting plasma glucose levels are less than 100 mg/dL. Fasting (POL-ee-YOOR-ree-ah): excessive urine production.
566 CHAPTER 20 Nutrition and Diabetes Mellitus

at which the kidneys begin to pass glucose into the urine ( ). The pres- TABLE 20-1 Symptoms of
ence of glucose in the urine draws additional water from the blood, increasing Diabetes Mellitus
the amount of urine produced. Thus, the symptoms that arise in diabetes may
● Excessive urine production (polyuria)
include excessive urine production ( ), dehydration, and excessive thirst
● Dehydration, dry mouth
( ). Some people lose weight and have excessive hunger ( ) as
a result of the nutrient depletion that occurs when insulin is deficient. Another ● Excessive thirst (polydipsia)
potential consequence of hyperglycemia is blurred vision, caused by the expo- ● Weight loss
sure of eye tissues to fluids. Increased infections are common in ● Excessive hunger (polyphagia)
individuals with diabetes and may be due to weakened immune responses and ● Blurred vision
impaired circulation. In some cases, constant fatigue is the only symptom and ● Increased in ections
may be related to altered energy metabolism, dehydration, or other effects of ● Fatigue
the disease.
Diagnosis of Diabetes Mellitus BOx 20-2 Nursing Diagnosis

The diagnosis of diabetes is based primarily on plasma glucose levels, which can
Nursing diagnoses or people with
be measured under fasting conditions or at random times during the day. In some
diabetes may include risk for unstable
cases, an t t t is given: the individual ingests a 75-gram glu-
blood glucose level, risk for deficient
cose load, and plasma glucose is measured at one or more time intervals following fluid volume, and risk for infection.
glucose ingestion. g t (h a1 ) levels, which reflect hemoglobin’s
exposure to glucose over the preceding two to three months, are an indirect assess-
ment of blood glucose levels. The following criteria are currently used to diagnose
diabetes:3
● The plasma glucose concentration is 126 mg/dL or higher after at least 8 hours of
fasting (normal fasting plasma glucose levels are 75 to 100 mg/dL). : having an
● In a person with classic symptoms of hyperglycemia, the plasma glucose abnormally high osmolarity;
concentration of a random, or casual, blood sample (that is, obtained from a osmolarity re ers to the
concentration o osmotically active
nonfasting individual) is 200 mg/dL or higher. particles in solution. Hyperglycemia
● The plasma glucose concentration measured two hours after a 75-gram glucose may cause some body luids to
load is 200 mg/dL or higher. become hyperosmolar.
● The HbA1c level is 6.5 percent or higher. t t t: a test
that evaluates a person’s ability to
Following a preliminary diagnosis of diabetes by clinical testing, confirmation is tolerate an oral glucose load.
required either by the presence of overt symptoms or a follow-up blood test that yields
t (h a1 ):
similar results.
hemoglobin that has
The term t is used when an individual’s blood glucose levels are above nonenzymatically attached to
normal but not high enough to be classified as diabetes; that is, between 100 and glucose; the level o HbA1c in the
125 mg/dL when fasting or between 140 and 199 mg/dL when measured two hours blood helps to diagnose diabetes
after ingesting a 75-gram glucose load.4 HbA1c levels between 5.7 and 6.4 percent and evaluate long-term glycemic
control. Also called glycosylated
also suggest prediabetes. Although people with prediabetes are usually asymptom-
hemoglobin.
atic, they are at high risk of eventually developing type 2 diabetes (described in a later
section) and cardiovascular diseases. Prediabetes affects approximately 34 percent of t : the state o having
plasma glucose levels that are
adults in the United States5 and 23 percent of adolescents aged 12 to 19 years,6 and it higher than normal but not high
is especially prevalent among those who are overweight or obese. enough to be diagnosed as
diabetes; occurs in individuals who
have metabolic de ects that o ten
Types of Diabetes Mellitus lead to type 2 diabetes.
Table 20-2 lists features of the two main types of diabetes, type 1 and type 2 diabetes. t 1 t : diabetes that is
Pregnancy can lead to abnormal glucose tolerance and the condition known as gesta- characterized by absolute insulin
tional diabetes (discussed later in this chapter), which often resolves after pregnancy de iciency, usually resulting rom the
but is a risk factor for type 2 diabetes. Diabetes can also be caused by medications that autoimmune destruction o pancreatic
beta cells.
cause glucose intolerance (such as steroids) and medical conditions that damage the
pancreas or interfere with insulin function. t : re ers to an immune
response directed against the body’s
own tissues.
T 1 d t T 1 t accounts for about 5 to 10 percent of diabetes
auto 5 sel
cases. 7 It is usually caused by t destruction of the pancreatic beta cells,
Overview of Diabetes Mellitus 567

TABLE 20-2 Features of Type 1 and Type 2 Diabetes Mellitus
feaTure Type 1 diabeTes Type 2 diabeTes
p t t 5–10% o cases 90–95% o cases
a t ,30 years .40 yearsa
a t t Autoimmune diseases, viral in ection, inherited Obesity, aging, inactivity, inherited actors
actors
m j t Destruction o pancreatic beta cells; insulin Insulin resistance; insulin de iciency relative
de iciency to needs
i t Little or none Varies; may be normal, increased, or decreased
r q t t All cases Some cases
f Juvenile-onset diabetes Adult-onset diabetes

Insulin-dependent diabetes Noninsulin-dependent diabetes
a
Incidence o type 2 diabetes is increasing in children and adolescents; in more than 90% o these cases, it is associated with overweight or obesity and a amily
history o type 2 diabetes.
Photo 20-1 Pancreatic Insulin Production which produce and secrete insulin (see Photo 20-1). By
the time symptoms develop, the damage to the beta cells
has progressed so far that insulin must be provided exog-
enously, most often by injection. Although the reason
for the autoimmune attack is usually unknown, environ-
mental toxins or infections are likely triggers. People with
Ed Reschke/Peter Arnold/Getty Images
type 1 diabetes often have a genetic susceptibility for the

disorder and are at increased risk of developing other
autoimmune diseases.
Type 1 diabetes typically develops during childhood or
adolescence, although it may occur at any age. Diagnosis
often follows an unrelated illness, which increases insulin
requirements and stresses the limited reserve of the defec-
tive pancreatic beta cells.8 Hence, classic symptoms of hyper-
Cross-sections o the pancreas reveal small clusters o cells glycemia (polyuria, polydipsia, weight loss, and weakness or
known as the islets o Langerhans; these regions contain fatigue) may appear abruptly in a previously healthy child
the beta cells that produce insulin. or young adult. Disease onset tends to be more gradual in
individuals who develop type 1 diabetes in later years. Blood
tests that detect antibodies to insulin, pancreatic islet cells, and pancreatic enzymes can
confirm the diagnosis and help to predict risk of the disease in close relatives.
T 2d t T 2 t is the most prevalent form of diabetes, accounting

for 90 to 95 percent of cases. 9 It is often asymptomatic for many years before diagno-
sis. The defect in type 2 diabetes is t , the reduced sensitivity to insulin
t 2 t : diabetes that is in muscle, adipose, and liver cells, coupled with relative insulin deficiency, the lack
characterized by insulin resistance of sufficient insulin to manage glucose effectively. Normally, the pancreatic beta cells
coupled with insu icient insulin secrete more insulin to compensate for insulin resistance. In type 2 diabetes, insu-
secretion.
lin levels are often abnormally high ( ) but the additional insulin is
t : reduced insufficient to compensate for its diminished effect in cells. Thus, the hyperglycemia
sensitivity to insulin in muscle, that develops represents a mismatch between the amount of insulin required and
adipose, and liver cells.
the amount produced by beta cells. Beta cell function tends to worsen over time in
: abnormally high people with type 2 diabetes, and insulin production gradually declines as the condi-
levels o insulin in the blood.
tion progresses.

Although the precise causes of type 2 diabetes are unknown, risk is substantially
increased by obesity (especially abdominal obesity), aging, and physical inactivity.
More than 80 percent of individuals with type 2 diabetes are obese, and obesity itself
can directly cause some degree of insulin resistance (see Nutrition in Practice 20).10
Prevalence increases with age and exceeds 25 percent in persons aged 65 years or
older; however, many cases remain undiagnosed.11 Genetic factors strongly influ-
ence risk, as type 2 diabetes is more prevalent in certain ethnic groups, including
African Americans, Hispanic/Latino populations, Native Americans, Asian Indians,
and Pacific Islanders.
T 2d t c a t Although most cases of type 2 dia-

betes are diagnosed in individuals who are over 40 years old, children and teenagers
who are overweight or obese or have a family history of diabetes are at increased risk.
Because type 2 diabetes is frequently asymptomatic, it is generally identified in youths
only when high-risk groups are screened for the disease.
Increased rates of both type 1 and type 2 diabetes have been documented in children
in past decades and correlate with the rise in childhood obesity. Type 1 and type 2 dia-
betes are sometimes difficult to distinguish in children, however, and a few studies have
found that some children diagnosed with one of these types of diabetes actually had the
other type.12 Note that type 2 diabetes is still extremely rare in children; for example, its
estimated incidence in 10- to 19-year-old African-American and Hispanic-American
youths—two groups at high risk—is about 33 and 18 cases per 100,000 individuals per
year, respectively.13 Its increasing prevalence, however, indicates that routine screening
and diabetes prevention programs may be important safeguards for children at risk.
Prevention of Type 2 Diabetes Mellitus

Clinical trials have shown that intensive lifestyle changes can prevent or delay the
development of type 2 diabetes in individuals at risk for as long as 10 to 20 years. 14
Based on the results of these studies, guidelines for diabetes prevention include the
following strategies:
● Weight management. A sustained weight loss of at least 7 percent of body weight is
recommended for overweight and obese individuals with prediabetes. Individuals
who cannot achieve weight loss should avoid gaining additional weight.
● Dietary modifications. Diets rich in whole grains, fruits, vegetables, legumes, and
nuts and low in refined grains, red meat, and sugar-sweetened beverages may
reduce diabetes risk.15 In addition, individuals who attempt weight loss may need
to reduce dietary fat to avoid consuming excessive energy.
● Physical activity. At least 150 minutes of moderate physical activity (such as brisk
walking) is recommended weekly; the activity should be conducted in at least three
separate sessions during the week.
● Regular monitoring. Individuals with prediabetes should be monitored yearly to
check for the development of diabetes.*
Acute Complications of Diabetes Mellitus

Untreated or poorly controlled diabetes may result in life-threatening complications.
Insulin deficiency can cause significant disturbances in energy metabolism, and severe
hyperglycemia can lead to dehydration and electrolyte imbalances. In treated diabetes,
(low blood glucose) is a possible complication of inappropriate disease
management. Figure 20-1 presents an overview of some of the effects of insulin insuf-
ficiency on energy metabolism.
*The antidiabetic medication metformin may be beneficial for preventing diabetes in high-risk individuals, such
as those who are very obese, have severe or worsening hyperglycemia, or have a history of gestational diabetes.

FIGURE 20-1 Effects of Insulin Insufficiency
The e ects o insulin insu iciency can be grouped according to the changes in carbohydrate, protein, and at metabolism.
Insulin insufficiency
Glycogen Glucose Triglyceride Triglyceride Protein Protein

breakdown uptake breakdown in synthesis in breakdown synthesis
by cells adipose adipose
tissue tissue
Hyperglycemia Blood fatty Muscle Blood

acids wasting, amino acids
growth
retardation
Glycosuria Blood Fatty acid VLDLa Weight loss Glucose

osmolarity oxidation in production in production in
the liver the liver the liver
Polyuria, Ketone Hypertriglyceridemia Aggravation of

dehydration body hyperglycemia
production
Polydipsia Nervous Ketoacidosis

system
malfunction
aVery-low-density lipoproteins; these lipoproteins transport triglycerides from the liver to other tissues.
d t K t T 1d t A severe lack of insulin causes diabetic keto-

acidosis. Without insulin, glucagon’s effects become more pronounced, leading to the
unrestrained breakdown of the triglycerides in adipose tissue and the protein in muscle.
As a result, an increased supply of fatty acids and amino acids arrives in the liver, fuel-
ing the production of ketone bodies and glucose. Ketone bodies, which are acidic, can
reach dangerously high levels in the bloodstream (ketoacidosis) and spill into the urine
(k t ). Blood pH typically falls below 7.30 (blood pH normally ranges between 7.35
and 7.45). Blood glucose levels usually exceed 250 mg/dL and rise above 1000 mg/dL in
severe cases. The main features of diabetic ketoacidosis therefore include severe k t
(abnormally high levels of ketone bodies), acidosis, and hyperglycemia.16
Patients with ketoacidosis may exhibit symptoms of both acidosis and dehydra-
BOx 20-3 Nursing Diagnosis tion (see Box 20-3). Acidosis is partially corrected by exhalation of carbon dioxide,
Nursing diagnoses or people with so rapid or deep breathing is characteristic.* Ketone accumulation is sometimes
diabetic ketoacidosis or hyperosmolar evident by a fruity odor on a person’s breath ( t t ). Significant urine loss
hyperglycemic syndrome may include (polyuria) accompanies the hyperglycemia, lowering blood volume and blood pres-
ineffective health management, sure and depleting electrolytes. In response, patients may demonstrate marked fatigue,
deficient fluid volume, risk for
electrolyte imbalance, and acute *Bicarbonate is a buffer in the blood that corrects acidosis. The acid (H1) combines with bicarbonate (HCO32) to
confusion. form carbonic acid (H2CO3), which breaks down to water (H2O) and carbon dioxide (CO2). The carbon dioxide
is then exhaled.

lethargy, nausea, and vomiting. The mental state may vary from alert to comatose
( t ). Treatment of diabetic ketoacidosis includes insulin therapy to correct
the hyperglycemia, intravenous fluid and electrolyte replacement, and, in some cases,
bicarbonate therapy to treat acidosis.
Diabetic ketoacidosis is sometimes the earliest sign that leads to a diagnosis of type 1
diabetes, but more often it results from inadequate insulin treatment, illness or infec-
tion, alcohol abuse, or other physiological stressors. The condition usually develops
quickly, within one to two days. Mortality rates are generally less than 5 percent but
may exceed 20 percent among very old individuals or patients with profound coma. 17
Although diabetic ketoacidosis can occur in type 2 diabetes—usually due to severe
stressors such as infection, trauma, or surgery—it develops less often because even rela-
tively low insulin concentrations are able to suppress ketone body production.
h h s T 2 d t The
is a condition of severe hyperglycemia and dehydration that
develops in the absence of significant ketosis. As mentioned earlier, the hyperglyce-
mia that develops in poorly controlled diabetes leads to polyuria, which results in
substantial fluid and electrolyte losses. In the hyperosmolar hyperglycemic syndrome,
patients are unable to recognize thirst or adequately replace fluids due to age, illness,
sedation, or incapacity. The profound dehydration that eventually develops exacer-
bates the rise in blood glucose levels, which often exceed 600 mg/dL and may climb
above 1000 mg/dL. Blood plasma may become so hyperosmolar as to cause neurologi-
cal abnormalities, such as confusion, speech or vision impairments, muscle weakness,
abnormal reflexes, and seizures; about 10 percent of patients lapse into coma.18 Treat-
ment includes intravenous fluid and electrolyte replacement and insulin therapy.
The hyperosmolar hyperglycemic syndrome is sometimes the first sign of type 2
diabetes in persons with undiagnosed diabetes. It is usually precipitated by an infec-
tion, serious illness, or drug treatment that impairs insulin action or secretion. Unlike
diabetic ketoacidosis, the condition often evolves slowly, over one week or longer; the
absence of clinical symptoms can delay its diagnosis. The mortality rate may be as high
as 20 percent, in part because the condition occurs more often in older patients with
cardiovascular disease or other major illnesses.19
h Hypoglycemia, or low blood glucose, is the most frequent complica-
tion of type 1 diabetes and may occur in type 2 diabetes as well. It is due to the inap-
propriate management of diabetes rather than to the disease itself, and is usually caused
by excessive dosages of insulin or antidiabetic drugs, prolonged exercise, skipped or
delayed meals, inadequate food intake, or the consumption of alcohol without food.
Hypoglycemia is the most frequent cause of coma in insulin-treated patients and is
believed to account for 4 to 10 percent of deaths in this population.20
Symptoms of hypoglycemia include sweating, heart palpitations, shakiness, hunger,
weakness, dizziness, and irritability. Mental confusion may prevent a person from rec-
ognizing the problem and taking corrective action such as ingesting glucose tablets,
juice, or candy (see Box 20-9 on p. 582). If hypoglycemia occurs during the night,
patients may be completely unaware of its presence.
Chronic Complications of Diabetes Mellitus

Prolonged exposure to high glucose concentrations can damage cells and tissues.
Glucose nonenzymatically combines with proteins, producing molecules that even-
tually break down to form reactive compounds known as t
t (age ); in diabetes, these AGEs accumulate to such high levels that they alter
the structures of proteins and stimulate metabolic pathways that are damaging to t t
tissues. In addition, excessive glucose promotes the production and accumulation of (age ): reactive compounds
sorbitol, which increases oxidative stress within cells and causes cellular injury. ormed a ter glucose combines with
Chronic complications of diabetes typically involve the large blood vessels protein; AGEs can damage tissues
and lead to diabetic complications.
( t ), smaller vessels such as arterioles and capillaries

BOx 20-4 Nursing Diagnosis
( t ), and the nerves ( t t ). Other tissues
adversely affected include the lens of the eye and the skin; cataracts, glaucoma,
Nursing diagnoses or persons with and various types of skin lesions sometimes develop. Infections are common in
chronic complications o diabetes may diabetes, a possible consequence of hyperglycemia, impaired circulation, and/or
include ineffective peripheral tissue
depressed immune responses (see Box 20-4). Many of these complications appear
perfusion, risk for infection, risk for
15 to 20 years after the onset of diabetes.21 In individuals with type 2 diabetes, com-
impaired skin integrity, and risk for
injury.
plications often develop before diabetes is diagnosed.
m c t The damage caused by diabetes accelerates the devel-
opment of atherosclerosis in the arteries of the heart, brain, and limbs. Moreover, type
2 diabetes is frequently accompanied by multiple risk factors for cardiovascular disease,
including hypertension and blood lipid abnormalities. People with diabetes also have
increased tendencies for thrombosis (blood clot formation) and abnormal ventricle
function, both of which can worsen the clinical course of heart disease. As a result of
cardiovascular complications, the most common causes of death in individu-
als with long-term diabetes are heart attack and stroke.22
Photo 20-2 Diabetic Foot Ulcer
About 20 to 30 percent of individuals with diabetes develop
(impaired blood circulation in the limbs),23 which increases the
risk of t (pain while walking) and contributes to the development of
foot ulcers (see Photo 20-2). Left untreated, foot ulcers can lead to
(tissue death), and some patients require foot amputation, a major cause of
disability in individuals with diabetes.
m c t Long-term diabetes is associated with detri-

mental changes in capillary structure and function, including the thickening of
SPL/Science Source
basement membranes, growth of fibrous tissue (scarring), increased capillary

permeability, and proliferation of vessels that function abnormally. The pri-
mary microvascular complications involve the retina of the eye and the kidneys.
In t t t , the weakened capillaries of the retina leak fluid, lip-
Foot ulcers are a common complication ids, or blood, causing local edema or hemorrhaging. The defective blood flow
o diabetes because blood circulation is also leads to damage and scarring within retinal tissue. New blood vessels
impaired, which slows healing, and nerve eventually form, but they are fragile and bleed easily, releasing blood and pro-
damage dampens oot pain, delaying
recognition and treatment o cuts and
teins that obscure vision. About 60 to 80 percent of diabetes patients develop
bruises. retinopathy 15 to 20 years after diagnosis.24 Retinopathy progresses most rap-
idly when diabetes is poorly controlled, and intensive diabetes management
substantially reduces the risk.
In t t , damage to the kidneys’ specialized capillaries prevents ade-
quate blood filtration, resulting in abnormal urinary protein losses ( ). As the
kidney damage worsens, urine production decreases and nitrogenous wastes accumu-
late in the blood; eventually, the individual requires dialysis (artificial filtration of blood)
to survive. Because the kidneys normally regulate blood volume and blood pressure,
inadequate kidney function may also result in hypertension. At least 20 to 40 percent of
persons with diabetes develop some degree of nephropathy, although a greater fraction
of type 1 patients progress to kidney failure.25 As with diabetic retinopathy, intensive
diabetes management can help slow the progression of kidney damage.
d t n t Diabetic neuropathy often involves the peripheral nerves (periph-
eral neuropathy) and nerves that control body organs and glands (autonomic neuropa-
thy). Peripheral neuropathy—the most common form of neuropathy in diabetes—may
be experienced as pain, numbness, or tingling in the hands, feet, and legs or weakness
of the limbs. Peripheral neuropathy also contributes to the development of foot ulcers
because cuts and bruises may go unnoticed until wounds are severe. Autonomic neu-
ropathy may be indicated by sweating abnormalities, disturbed bladder function, erec-
tile dysfunction, delayed stomach emptying ( t ), constipation, and cardiac
arrhythmias. Neuropathy occurs in about 50 percent of patients with diabetes;26 the
extent of nerve damage depends on the severity and duration of hyperglycemia.

Review Notes
● Diabetes mellitus is a chronic condition characterized by inadequate insulin secretion and/or
impaired insulin action. Diagnosis is based on indicators o hyperglycemia.
● In type 1 diabetes, the pancreas secretes little or no insulin, and insulin therapy is
necessary or survival. Type 2 diabetes is characterized by insulin resistance coupled with
relative insulin de iciency.
● Acute complications o poorly controlled diabetes include diabetic ketoacidosis, in
which hyperglycemia is accompanied by ketosis and acidosis, and the hyperosmolar
hyperglycemic syndrome, characterized by severe hyperglycemia, dehydration, and
possible mental impairments. Another acute complication, hypoglycemia, is most o ten a
consequence o inappropriate disease management.
● Chronic complications o diabetes include macrovascular disorders such as cardiovascular
and peripheral vascular diseases, microvascular conditions such as retinopathy and
nephropathy, and neuropathy.
20.2 Treatment of Diabetes Mellitus

Diabetes is a chronic and progressive illness that requires lifelong treatment. Managing
blood glucose levels is a delicate balancing act that involves meal planning, proper
timing of medications, and physical exercise. Frequent adjustments in treatment are
often necessary to establish good control. Individuals with type 1 diabetes
require insulin therapy for survival. Type 2 diabetes may initially be treated with
nutrition therapy and exercise, but most patients eventually need to add antidiabetic
medications or insulin. Diabetes management becomes even more difficult once com-
plications develop. Although the health care team must determine the appropriate
therapy, the individual with diabetes ultimately assumes much of the responsibility for
treatment and therefore requires education in self-management of the disease.
Treatment Goals
The main goal of diabetes treatment is to maintain blood glucose levels within a desir-
able range to prevent or reduce the risk of complications. Several multicenter clinical
trials have shown that intensive diabetes treatment, which keeps blood glucose lev-
els tightly controlled, can greatly reduce the incidence and severity of some chronic
complications.*27 Therefore, maintenance of near-normal glucose levels has become
the fundamental objective of diabetes care plans. Other goals of treatment include
maintaining healthy blood lipid concentrations, controlling blood pressure, and man-
aging weight—measures that can help to prevent or delay diabetes complications as
well. Table 20-3 provides examples of some major differences between conventional
and intensive therapies for type 1 diabetes. For type 2 diabetes, intensive therapy
involves the addition of certain medications or insulin to standard dietary and life-
style modifications. Note that intensive therapy is recommended only if the benefits of
therapy outweigh the potential risks, and it may be inappropriate for some individuals
(gly-SEE-mic): pertaining
(including those with limited life expectancies, history of hypoglycemia, or previous
to blood glucose.
heart disease).
c t d t e t :
Diabetes education provides an individual with the knowledge and skills necessary
a health care pro essional who
to implement treatment. The primary instructor is often a c t d t e t ,a specializes in diabetes management
education; certi ication is obtained
rom the National Certi ication
*Studies that evaluated the benefits of intensive treatment include the Diabetes Control and Complications Trial
Board or Diabetes Educators.
and the United Kingdom Prospective Diabetes Study.
Treatment of Diabetes Mellitus 573

TABLE 20-3 Comparison of Conventional and Intensive Therapies
for Type 1 Diabetesa
convenTional Therapy inTensive Therapy
b Monitored daily Monitored at least three times daily
t
i One or two daily injections; Three or more daily injections or use o an

t no daily adjustments external insulin pump; dosage adjusted
according to the results o blood glucose
monitoring and expected carbohydrate intake
a t Fewer incidences o severe Delayed progression o retinopathy,

hypoglycemia; less weight gain nephropathy, and neuropathy
d t More rapid progression o Two old to three old increase in severe

retinopathy, nephropathy, and hypoglycemia; weight gain; increased risk o
BOx 20-5
neuropathy becoming overweight
Goals or glycemic control in adults
a
(nonpregnant): The therapies shown here were compared in the Diabetes Control and Complications Trial, which was conducted in
patients with type 1 diabetes. For type 2 diabetes, intensive therapy involves the addition o certain medications or
●
Be ore meals: 80–130 mg/dL insulin to standard dietary and li estyle modi ications.
b
●
1 to 2 hours a ter the start o a meal: In the Diabetes Control and Complications Trial, insulin therapy was conducted using various mixtures o short-
,180 mg/dL acting, intermediate-acting, and long-acting insulins. Since the study, a variety o other insulin therapies have been
developed (including rapid-acting insulin and long-acting insulin analogs), allowing or treatments associated with
● HbA 1c : ,7.0% less risk o hypoglycemia.
Photo 20-3 Self-Monitoring of Blood Glucose health care professional (often a nurse or dietitian) who has special-
ized knowledge about diabetes treatment and the health education
process. To manage diabetes, patients need to learn about appro-
priate meal planning, medication administration, blood glucose
monitoring, weight management, appropriate physical activity, and
prevention and treatment of diabetic complications.
Piotr Adamowicz/Shutterstock.com
Evaluating Diabetes Treatment

Diabetes treatment is largely evaluated by monitoring glycemic
status. Good glycemic control requires frequent testing of blood
glucose levels using a glucose meter, referred to as -
t (see Box 20-5 and Photo 20-3). Glucose
testing provides valuable feedback when the patient adjusts food
Sel -monitoring o blood glucose involves applying a drop intake, medications, and physical activity and is helpful for pre-
o blood rom a inger prick to a chemically treated paper
strip, which is then analyzed or glucose.
venting hypoglycemia. Ideally, patients with type 1 diabetes
should measure blood glucose levels prior to meals and snacks,
at bedtime, prior to exercise or critical tasks such as driving, when-
ever they suspect hypoglycemia, and after treating hypoglycemia.28 Some patients
may achieve better glycemic control by also using a t t
system, which measures tissue glucose levels every few minutes using a tiny sensor
placed under the skin. Although self-monitoring of blood glucose is also useful in
type 2 diabetes, the recommended frequency varies according to the specific needs
- t : of individual patients.
home monitoring o blood glucose
levels using a glucose meter. l -T g c t Health care providers periodically evaluate long-term
t t : glycemic control by measuring HbA1c levels. The glucose in blood freely enters red
continuous monitoring o tissue blood cells and attaches to hemoglobin in direct proportion to the amount of glu-
glucose levels using a small sensor cose present. The percentage of HbA1c in hemoglobin reflects glycemic control over
placed under the skin.
the preceding two to three months, the average age of circulating red blood cells

(Box 20-6 shows how HbA1c correlates with average plasma glucose levels). The goal of BOx 20-6
diabetes treatment is usually an HbA1c value less than 7 percent, but the percentage is
often markedly higher in people with diabetes, even those who are maintaining near- Comparison o HbA1c and plasma
normal blood glucose levels. Less stringent HbA 1c goals (for example, a value less than glucose levels:
8 percent) may be suitable for some patients, including those with limited life expec- a
tancy, advanced diabetic complications, or a history of severe hypoglycemia. HbA 1c h a1 (%) ( / l)
testing is typically conducted two to four times yearly. 6a
126
The t t t is sometimes conducted to determine glycemic control over 7 154
the preceding two to three weeks. This test determines the nonenzymatic glycation of 8 183
serum proteins (primarily albumin), which have a shorter half-life than hemoglobin. 9 212
Most often, the fructosamine test is used to evaluate recent adjustments in diabetes a
HbA1c is typically ,6% in nondiabetics.
treatment or glycemic control during pregnancy. The test cannot be used if the patient
has a liver or kidney disorder that lowers serum protein levels.
K t T t Ketone testing, which checks for the development of ketoacidosis,

should be performed if symptoms are present or if risk has increased due to acute
illness, stress, or pregnancy. Both blood and urine tests are available for home use,
although the blood tests are generally more reliable. Ketone testing is most useful for
patients who have type 1 diabetes or are pregnant. Individuals with type 2 diabetes may
produce excessive ketone bodies when severely stressed by infection or trauma.
m t l -T c t Individuals with diabetes are routinely mon-

itored for signs of long-term complications. Blood pressure is measured at each checkup.
Annual lipid screening is suggested for adult patients. Routine checks for urinary protein
(albuminuria) can determine whether nephropathy has developed. Physical examina-
tions generally screen for signs of retinopathy, neuropathy, and foot problems.
Nutrition Therapy: Dietary Recommendations

Nutrition therapy can improve glycemic control and slow the progression of diabetic
complications. As always, the nutrition care plan must consider personal preferences
and lifestyle habits. In addition, dietary intakes must be modified to accommodate
growth, lifestyle changes, aging, and any complications that develop. Although all
members of the diabetes care team should understand the principles of dietary treat-
ment, a registered dietitian is best suited to design and implement the nutrition ther- BOx 20-7
apy provided to diabetes patients. This section presents the dietary recommendations
for diabetes; a later section describes meal-planning strategies. m t t dri t :
Macronutrient ranges (% o total kcal):
● Carbohydrate: 45–65%
m t t i t k The recommended macronutrient distribution (percent
● Fat: 20–35%
of kcalories from carbohydrate, fat, and protein) depends on food preferences and
●
metabolic factors (for example, insulin sensitivity, blood lipid levels, and kidney func- Protein: 10–35%
tion).29 Intakes suggested for the general population are often used as a guideline Carbohydrate RDA: 130 g/day
(see Box 20-7). Day-to-day consistency in carbohydrate intake is associated with bet- Fiber AI: 21–38 g/day
ter glycemic control, unless the patient is undergoing intensive insulin therapy that
Protein RDA: 0.8 g/kg body weight
matches insulin doses to mealtime carbohydrate intakes.
T t c t i t k The amount of carbohydrate consumed 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 t t t: a measurement
on the person’s metabolic needs (which are related to the type of diabetes, degree of glu- o glycated serum proteins that
cose tolerance, and blood lipid levels), the type of insulin or other medications used to re lects glycemic control over the
manage the diabetes, and individual preferences. For optimal health, the carbohydrate preceding two to three weeks; also
sources should be vegetables, fruits, whole grains, legumes, and milk products, whereas known as the glycated albumin test
or the glycated serum protein test.
foods made with refined grains and added sugars should be limited.30

g i Different carbohydrate-containing foods have different effects on
blood glucose levels after they are ingested; for example, consuming a portion of white
rice causes blood glucose to increase more than would a similar portion of barley. A
food’s glycemic effect is influenced by the type of carbohydrate in a food, the food’s
fiber content, the preparation method, the other foods included in a meal, and indi-
vidual tolerances (see Nutrition in Practice 3 for details). For individuals with dia-
betes, choosing foods with a low (gi) over those with a high GI may
modestly improve glycemic control.31 A food’s glycemic effect is not usually a primary
consideration when treating diabetes, however, because clinical studies investigating
the potential benefits of low-GI diets on glycemic control have had mixed results. 32
Nonetheless, high-fiber, minimally processed foods—which typically have lower gly-
cemic effects than do highly processed, starchy foods—are among the foods frequently
recommended for persons with diabetes.
s A common misperception is that people with diabetes need to avoid sugar and
sugar-containing foods. In reality, table sugar (sucrose), made up of glucose and fruc-
tose, has a lower glycemic effect than starch. Because moderate consumption of sugar
has not been shown to adversely affect glycemic control,33 sugar recommendations for
people with diabetes are similar to those for the general population, which advise mini-
mizing foods and beverages that contain added sugars. However, sugars and sugary
foods must be counted as part of the daily carbohydrate allowance.
Although fructose has a minimal glycemic effect, its use as an added sweetener
should be limited because excessive dietary fructose may adversely affect blood lipids
and lipid metabolism (note that it is not necessary to avoid the naturally occurring
fructose in fruits and vegetables).34 Sugar alcohols (such as sorbitol and maltitol) have
lower glycemic effects than glucose or sucrose and may be used as sugar substitutes.
Artificial sweeteners (such as aspartame, saccharin, and sucralose) contain no digest-
ible carbohydrate and can be safely used in place of sugar.
W g f Recommendations for whole grain and fiber intakes are

similar to those for the general population. People with diabetes are encouraged to
include fiber-rich foods such as whole-grain cereals, legumes, fruits, and vegetables in
their diet. Although some studies have suggested that very high intakes of fiber (more
than 50 grams per day) may improve glycemic control, many individuals have difficulty
enjoying or tolerating such large amounts of fiber.35
d t f t A Mediterranean-style dietary pattern that emphasizes unsaturated fats

may benefit both glycemic control and cardiovascular disease (CVD) risk.36 In addi-
tion, increased intakes of omega-3 fatty acids from fatty fish or plant sources may
improve the lipoprotein profile and various other CVD risk factors (see Chapter 4).
Other guidelines related to fat intake are similar to those suggested for the general
population: saturated fat should be less than 10 percent of total kcalories and trans fats
(gi): a ranking o should be avoided.
carbohydrate oods based on their
e ect on blood glucose levels a ter p t Protein recommendations for people with diabetes are similar to those for
ingestion; oods with a low GI have the general population (see Box 20-7). In the United States, the average protein intake
a lesser glycemic e ect whereas
is about 16 percent of the energy intake. Although several small, short-term studies
those with a high GI have a greater
glycemic e ect. The website www have suggested that higher protein intakes (28 to 40 percent of total kcalories) may
.glycemicindex.com provides GI improve glycemic control or lipoprotein levels in diabetic individuals, other studies did
values or a wide variety o oods. not show any benefit.37 In addition, high protein intakes are sometimes discouraged
k: volume o an alcoholic because they may be detrimental to kidney function in patients with nephropathy.
beverage that contains about ½
ounce o pure ethanol; equivalent to a u d t Guidelines for alcohol intake are similar to those for the
12 oz o beer, 5 oz o wine, or 1½ oz o general population, which recommend that women and men limit their average daily
80-proo distilled spirits such as gin, intakes of alcohol to one k and two drinks per day, respectively. In addition, indi-
rum, vodka, and whiskey.
viduals using insulin or medications that promote insulin secretion should consume

food when they ingest alcoholic beverages to avoid hypoglycemia (alcohol can cause
hypoglycemia by interfering with glucose production in the liver).38 Conversely, an
excessive alcohol intake (three or more drinks per day) can worsen hyperglycemia and
raise triglyceride levels in some individuals. People who should avoid alcohol include
pregnant women and individuals with advanced neuropathy, abnormally high triglyc-
eride levels, or a history of alcohol abuse.
m t t Micronutrient recommendations for people with diabetes are the

same as for the general population. Vitamin and mineral supplementation is not
recommended unless nutrient deficiencies develop; those at risk include elderly indi-
viduals, pregnant or lactating women, strict vegetarians, and individuals on kcalorie-
restricted diets. Although various micronutrients (including chromium and antioxidant
nutrients such as vitamins C and E) have been tested for their potential benefits in
managing diabetes or diabetes complications, results have not been promising.39
e b W t T 2d t Because excessive body fat can worsen

insulin resistance, weight loss is recommended for overweight or obese individuals
who have diabetes. Even moderate weight loss (5 to 10 percent of body weight) can help
to improve insulin resistance, glycemic control, blood lipid levels, and blood pressure.
Weight loss is most beneficial early in the course of diabetes, before insulin secretion
has diminished.40
Nutrition Therapy: Meal-Planning Strategies

Dietitians provide a number of meal-planning strategies to help people with diabetes
maintain glycemic control. These strategies emphasize control of carbohydrate intake
and portion sizes. Initial dietary instructions may include guidelines for maintaining a
healthy diet, improving blood lipids, and reducing cardiovascular risk factors. Sample
menus that include commonly eaten foods can help to illustrate general principles.
People using intensive insulin therapy must learn to coordinate insulin injections with
meals and to match insulin dosages to carbohydrate intake, as discussed later.
c t c t Carbohydrate-counting techniques are simpler and more

flexible than other menu-planning approaches and are widely used for planning dia-
betes diets. Carbohydrate counting works as follows: After an interview in which the
dietitian learns about the patient’s usual food intake and calculates nutrient and energy
needs, the patient is given a daily carbohydrate allowance, divided into a pattern of
meals and snacks according to individual preferences. The carbohydrate allowance can
be expressed in grams or as the number of carbohydrate portions allowed per meal (see
Table 20-4). The user of the plan need only be concerned about meeting carbohydrate
goals and can select from any of the carbohydrate-containing food groups when plan-
ning meals (see Table 20-5 and Figure 20-2). Although encouraged to make healthy
food choices, the individual has the freedom to choose the foods desired at each meal
without risking loss of glycemic control. Some people may also need guidance about
consuming a diet that improves blood lipids or energy intakes. Box 20-8 shows how to
implement carbohydrate counting in clinical practice.
Carbohydrate counting is taught at different levels of complexity depending on a per-
son’s needs and abilities. The basic carbohydrate-counting method just described can
be helpful for most people, although it requires a consistent carbohydrate intake from
day to day to match the medication or insulin regimen. Advanced carbohydrate count-
ing allows more flexibility but is best suited for patients using intensive insulin therapy.
With this method, a person can determine the specific dose of insulin needed to cover
the amount of carbohydrate consumed in a meal. The person is then free to choose
the types and portions of food desired without sacrificing glycemic control. Advanced
carbohydrate counting requires some training and should be attempted only after an
individual has mastered more basic methods.

Bo 20-8 How to Use Carbohydrate Counting in Clinical Practice
1. The irst step in basic carbohydrate counting is to determine an Success with carbohydrate counting requires knowledge about
appropriate carbohydrate allowance and suitable distribution the ood sources o carbohydrates and an understanding o portion
pattern; an example is shown in Table 20-4. To ensure that the control. As shown in Table 20-5, ood selections that contain about
carbohydrate level will be acceptable to the person using the
plan, the dietitian can conduct a nutrition assessment to estimate TABLE 20-5 Carbohydrate-Containing Food
the person’s usual carbohydrate intake and ood habits. Frequent Groups and Sample Portion Sizes
monitoring o blood glucose levels can help to determine whether
additional carbohydrate restriction would be help ul. b , , , t : 1 portion 5 15 g carbohydrate
The example given in Table 20-4 illustrates a meal pattern or a ● 1 slice o bread or 1 small tortilla
person consuming 2000 kcalories daily with a carbohydrate allow- ● ½ English mu in
ance o 50 percent o kcalories. This is calculated as ollows: ● ¾ c unsweetened, ready-to-eat cereal
2000 kcal 3 50% 5 1000 kcal o carbohydrate ● ½ c cooked oatmeal
● ⅓ c cooked rice or pasta
1000 kcal carbohydrate
5 250 g carbohydrate/day
4 kcal/g carbohydrate
st t : 1 portion 5 15 g carbohydrate
250 g carbohydrate ● 1 small (3 oz) potato
5 16.7 carbohydrate portions/day
15 g/1 carbohydrate portion ● ½ c canned or rozen corn
● ½ c cooked beans
2. The distribution o carbohydrates among meals and snacks is based
● 1 c winter squash, cubed
on both individual pre erences and metabolic needs. In type 1 diabe-
tes, the insulin regimen must coordinate with the individual’s dietary
f t: 1 portion 5 15 g carbohydrate
and li estyle choices. People using conventional insulin therapy must
● 1 small (4 oz) apple
maintain a consistent carbohydrate intake rom day to day to match
● 1 medium (6 oz) peach
their particular insulin prescription, whereas those using intensive
therapy can alter insulin dosages when carbohydrate intakes ● ¾ c blueberries
change. People with type 2 diabetes are encouraged to develop ● ½ c apple or orange juice
dietary patterns that suit their li estyle and medication schedules.
For all types o diabetes, the carbohydrate recommendation may m k t : 1 portion 5 12 g carbohydrate; may be rounded
need to be altered periodically to improve blood glucose control. up to 15 g or ease in counting carbohydrate portions
● 1 c milk (whole, low- at, or at- ree)
3. Carbohydrate counting can be done in one o two ways:
● 1 c buttermilk
● Count the grams o carbohydrate provided by oods.
● 6 oz plain yogurt
●
Count carbohydrate portions, expressed in terms o servings that
contain about 15 grams o carbohydrate each.
sw t t :a Carbohydrate content varies; portions
listed contain approximately 15 g
● ½ c ice cream
TABLE 20-4 Sample Carbohydrate Distribution
● 2 sandwich cookies (with cream illing)
for a 2000-kCalorie Diet
● 1 small (¾ oz) granola bar
carbohydraTe alloWance ● 5 chocolate kisses
● 1 tbs honey
meals grams porTions
Break ast 60 4 n t t : 1 portion 5 approximately 5 g carbohy-
drate; 3 servings are equivalent to 1 carbohydrate portion; can be
Lunch 60 4
disregarded i ewer than 3 servings are consumed
A ternoon snack 30 2 ● ½ c cooked cauli lower
● ½ c cooked cabbage, collards, or kale
Dinner 75 5
● ½ c cooked okra
Evening snack 30 2
● ½ c diced or raw tomatoes
T t 255 17
a
Products sweetened with arti icial sweeteners or sugar alcohols contain
a
1 portion 5 15 g carbohydrate 5 1 portion o starchy ood, milk, or ruit. ewer grams o carbohydrate than products sweetened with sugar or honey.
Note: The carbohydrate allowance in this example is approximately 50% Note: Unprocessed meats, ish, and poultry contain negligible amounts
o total kcalories. o carbohydrate.
(Continued )

Bo 20-8 How to Use Carbohydrate Counting in Clinical Practice (continued )
15 grams o carbohydrate are interchangeable. The portions o oods does not contribute to blood glucose (some clinicians may suggest
that contain 15 grams may vary substantially, however, even among subtracting only hal o the grams o fber). I the sugar alcohol con-
oods in a single ood group. Accurate carbohydrate counting o ten tent is greater than 5 grams per serving, hal o the grams o sugar
requires instruction and practice in portion control using measuring alcohols can be subtracted rom the Total Carbohydrate value.
cups, spoons, and a ood scale. Food lists that indicate the carbohy- 4. Once they have learned the basic carbohydrate counting
drate content o common oods are available rom the American Dia- method, individuals can select whatever oods they wish as long
betes Association and the Academy o Nutrition and Dietetics; these as they do not exceed their carbohydrate goals. Figure 20-2
are help ul resources or learning carbohydrate-counting methods. shows a day’s menu that provides the carbohydrate allowance
When using packaged oods, individuals should check the Nutri- shown in Table 20-4. Although carbohydrate counting ocuses
tion Facts panel o ood labels to fnd the carbohydrate content o on a single macronutrient, people using this technique should
a serving. I the fber content is more than 5 grams per serving, it be encouraged to ollow a healthy eating plan that meets other
should be subtracted rom the Total Carbohydrate value, as fber dietary objectives as well.
FIGURE 20-2 Translating Carbohydrate Portions into a Day’s Meals
Carbohydrate Carbohydrate
Portions Portions
Carbohydrate goal 4 portions or 60 g Carbohydrate goal 2 portions or 30 g
Carbohydrate goal 5 portions or 75 g
f l t d t A meal-planning system originally developed for persons

with diabetes allows individuals to create an eating plan by choosing foods with
specified portions from a variety of food lists. The different food lists group foods
according to their proportions of carbohydrate, fat, and protein so that all items on
a particular list have similar macronutrient and energy contents (see Appendix C,
pp. C-1 to C-2). Thus, each food on a food list can be substituted for any other
food on the same list without affecting the macronutrient balance in a day’s meals.
Although the food list system may be helpful for individuals who want to maintain
a diet with specific macronutrient percentages, it is less flexible than carbohydrate
counting and offers no advantages for maintaining glycemic control. However, the

t (sub-cue-TAY-nee-us): food lists may be helpful resources for individuals using carbohydrate-counting
beneath the skin. methods because the portions are similar to the portions used in carbohydrate
: devices used or injecting
counting, providing about 15 grams of carbohydrate per food item (see pp. C-3 to
medications. A syringe consists o C-6; note that the carbohydrates in foods on the Milk and Milk Substitutes list can
a hypodermic needle attached to a be rounded up to 15 grams).
hollow tube with a plunger inside.
Insulin Therapy
Insulin therapy is necessary for individuals who cannot produce enough insulin to
meet their metabolic needs. It is therefore required by people with type 1 diabetes and
those with type 2 diabetes who cannot maintain glycemic control with medications,
diet, and exercise. The pancreas normally secretes insulin in relatively low amounts
between meals and during the night (called basal insulin) and in much higher amounts
when meals are ingested. Ideally, the insulin treatment should reproduce the natural
pattern of insulin secretion as closely as possible.
i p t The forms of insulin that are commercially available differ by

their onset of action, timing of peak action, and duration of effects. Table 20-6 and
Figure 20-3 show how insulin preparations are classified: they may be rapid acting
(lispro, aspart, glulisine, and inhaled insulin), short acting (regular), intermediate act-
ing (NPH), or long acting (glargine, detemir, and degludec), thereby allowing substan-
tial flexibility in establishing a suitable insulin regimen.41 The rapid- and short-acting
insulins are typically used at mealtimes, whereas the intermediate- and long-acting
insulins provide basal insulin for the periods between meals and during the night.
Thus, mixtures of several types of insulin can produce greater glycemic control than
any one type alone. Several premixed formulations are also available; examples are
listed in Table 20-6.
i d Insulin is most often administered by t injection, either

self-administered or provided by caregivers (note that insulin is a protein, and would
be destroyed by digestive processes if taken orally). Disposable , which are
filled from vials that contain multiple doses of insulin, are the most common devices
TABLE 20-6 Insulin Preparations

form of insulin common preparaTions onseT of acTion peaK acTion duraTion of acTion
Rapid acting Lispro (Humalog) 5–15 minutes 60–90 minutes 3–5 hours
Aspart (Novolog)
Glulisine (Apidra)
Inhaled insulin (A rezza)a
Short acting Regular (Humulin R, Novolin R) 30–60 minutes 2–3 hours 5–8 hours
Intermediate acting NPH (Humulin N, Novolin N) 2–4 hours 6–8 hours 10–18 hours
Long acting Glargine (Lantus) 1–2 hours Steady e ects 24 hours or

Detemir (Levemir) longer
Degludec (Tresiba)
Insulin mixtures (with NPH/regular (70:30) Variable; depends Variable; depends Variable; depends
sample ratios) NPL (modi ied lispro)/lispro (75:25) on ormulation on ormulation on ormulation
a
A rezza is a powdered insulin administered by inhalation; its peak action (53 minutes) occurs earlier than that o other rapid-acting insulin products.

FIGURE 20-3 Effects of Insulin Preparations
© Wadsworth, Cengage Learning

used for injecting insulin (see Photo 20-4). Another option is to use Photo 20-4 Insulin Injection
insulin pens, injection devices that resemble permanent marking pens.
Disposable insulin pens are prefilled with insulin and are used one
time only, whereas reusable pens can be fitted with prefilled insulin
cartridges and replaceable needles. A rapid-acting inhalation powder
Image Point Fr/Shutterstock.com
is available for use before meals, although it cannot be used by patients
with lung disease. Some individuals use insulin pumps, computerized
devices that infuse insulin through thin, flexible tubing that remains
in the skin; the pump can be attached to a belt or kept in a pocket (see
Photo 20-5). Some of the newer insulin pumps include built-in continu-
ous glucose monitoring systems.
i r T 1 d t Type 1 diabetes is best man- Children with diabetes o ten become adept
aged with intensive insulin therapy, which typically involves three or at administering the insulin they require.
four daily injections of several types of insulin or the use of an insulin
pump. 42 Insulin pumps are usually programmed to deliver low amounts
of rapid-acting insulin continuously (to meet basal insulin needs) and bolus doses
of rapid-acting insulin at mealtimes. In persons who inject insulin, intermediate- or
long-acting insulin meets basal insulin needs, and rapid- or short-acting insulin is
injected (or in some cases, administered via inhalation*) before meals. Simpler regi-
mens involve twice-daily injections of a mixture of intermediate- and short-acting
insulin. Regimens that include three or more injections allow for greater flexibility
in carbohydrate intake and meal timing. With fewer injections, the timing of both
meals and injections must be similar from day to day to avoid periods of insulin
deficiency or excess.
A person using intensive therapy must learn to accurately determine the amount
of insulin to inject before each meal. The amount required depends on the pre-meal
blood glucose level, the carbohydrate content of the meal, and the person’s body
weight and sensitivity to insulin. To determine insulin sensitivity, the individual
*The inhalation powder Afrezza is the only form of inhaled insulin on the market; it has not become a popular
alternative to injectable forms of insulin.

Photo 20-5 Insulin Pump keeps careful records of food intake, insulin dosages, and blood glucose
levels. Eventually, these records are analyzed by medical personnel to
determine the appropriate t -t - t for that individual,
which assists in calculating insulin doses at mealtime. Intensive therapy
allows for substantial variation in food intake and lifestyle, but it requires
frequent testing of blood glucose levels and a good understanding of
carbohydrate counting.
After insulin therapy is initiated, persons with type 1 diabetes may expe-
Click and Photo/Shutterstock.com

rience a temporary remission of disease symptoms and a reduced need for
insulin, known as the honeymoon period. The remission is due to a temporary
improvement in pancreatic beta-cell function and may last for several weeks
or months. It is important to anticipate this period of remission to avoid insu-
lin excess. In all cases, the honeymoon period eventually ends, and the patient
must reinstate full insulin treatment.43
An external insulin pump delivers a low i r T 2d t Although initial treatment of type 2

dosage o insulin continuously and bolus diabetes usually involves nutrition therapy, physical activity, and oral antidia-
doses at mealtimes. Insulin therapy betic medications, long-term results with these treatments are often disap-
using an insulin pump is also known as
continuous subcutaneous insulin infusion.
pointing. As the disease progresses, pancreatic function worsens, and many
individuals require insulin therapy to maintain glycemic control.
Many possible regimens can be used to control type 2 diabetes.44 Most per-
sons use insulin in combination with one or more antidiabetic drugs, although some
individuals may be treated with insulin alone. Many patients need only one or two
daily injections. In some cases, an injection of an intermediate- or long-acting form of
insulin may be needed once or twice a day. Other regimens may involve two or more
daily injections of an insulin mixture that includes both a rapid- or short-acting insulin
and an intermediate- or long-acting insulin. Doses and timing are adjusted according
to the results of blood glucose self-monitoring.
i T h Hypoglycemia (blood glucose levels below

70 mg/dL) is the most common complication of insulin treatment, although it may also
result from the use of some oral antidiabetic drugs. It most often results from inten-
sive insulin therapy because the attempt to attain near-normal blood glucose levels
increases the risk of overtreatment. Other potential causes include skipped meals or
snacks or prolonged exercise.
Hypoglycemia can be corrected by consuming glucose or a glucose-containing
BOx 20-9
food. Usually, 15 to 20 grams of carbohydrate (see Box 20-9) can relieve hypogly-
Each o the ollowing sources provides cemia in about 15 minutes, although patients should monitor their blood glucose
about 15 g o carbohydrate: levels in case additional treatment is necessary. 45 Foods that provide pure glucose
● Glucose tablets: 4 tablets yield a better response than foods that contain other sugars, such as sucrose or
● fructose. Individuals who use insulin are usually advised to carry glucose tablets
Table sugar: 1 tbs
● Honey: 1 tbs or a source of carbohydrate that can be easily ingested. After blood glucose nor-
● Hard candy: 3 pieces
malizes, patients should consume a meal or snack to prevent recurrence. Those at
●
risk of severe hypoglycemia (blood glucose levels below 54 mg/dL) are often given
Orange juice: ½ c
prescriptions for the hormone glucagon, which can be injected by caregivers in case
of unconsciousness.
i T W tg Weight gain is sometimes an unintentional side
effect of insulin therapy, especially in individuals undergoing intensive insulin treat-
ment. Although the exact causes of the weight gain are unclear, it may partly be due
t -t - t : to insulin’s stimulatory effect on fat synthesis. Patients may be able to avoid weight
the amount o carbohydrate that gain by reducing the ratio of basal to mealtime insulin and improving carbohy-
can be handled per unit o insulin; drate-counting skills to obtain better estimates of mealtime insulin requirements.46
on average, every 15 grams o Concerns about weight should not discourage the use of intensive therapy, which
carbohydrate requires about 1 unit o is associated with longer life expectancy and fewer complications than occur with
rapid- or short-acting insulin.
conventional therapy.

f t h Insulin therapy must sometimes be adjusted to prevent
t , which typically develops in the early morning after an over-
night fast of at least eight hours. The usual cause is a waning of insulin action during
the night due to insufficient insulin dosing the evening before. A second possibility,
known as the w , is an increase of blood glucose in the morning due
to the early-morning secretion of growth hormone, which reduces insulin sensitivity.
Less frequently, fasting hyperglycemia develops as a result of nighttime hypoglyce-
mia, which causes the secretion of hormones that stimulate glucose production; the
resulting condition is known as (also called the Somogyi effect).
Whatever the cause, fasting hyperglycemia can be treated by adjusting the dosage or
formulation of insulin administered in the evening.47
Antidiabetic Drugs
Treatment of type 2 diabetes often requires the use of oral medications and injectable
drugs other than insulin. As shown in Table 20-7, these drugs can improve hypergly-
cemia by various modes of action. Treatment may involve the use of a single medica-
tion (monotherapy) or a combination of several medications (combination therapy).
By utilizing several mechanisms at once, combination therapy achieves more rapid and
sustained glycemic control than is possible with monotherapy. Box 20-10 lists some
nutrition-related effects of several antidiabetic drugs.
TABLE 20-7 Antidiabetic Drugs

drug caTegory common examples mode of acTion
Alpha-glucosidase Acarbose (Precose) Delay carbohydrate digestion and
inhibitors Miglitol (Glyset) absorption
Amylin analogs Pramlintide (Smylin) Suppress glucagon secretion, delay stomach

(injected) emptying, increase satiety
Biguanides Met ormin (Glucophage) Inhibit liver glucose production, improve

glucose utilization
Bile acid sequestrants Colesevelam (Welchol) Unknown; may inhibit liver glucose production
Dipeptidyl peptidase 4 Saxagliptin (Onglyza) Improve insulin secretion, suppress glucagon

(DPP-4) inhibitors Sitagliptin (Januvia) secretion, delay stomach emptying
Dopamine D2 receptor Bromocriptine (Cycloset) Increase insulin sensitivity

agonists
GLP-1 receptor agonists Exenatide (Byetta) Improve insulin secretion, suppress

(injected) Liraglutide (Victoza) glucagon secretion, delay stomach t :
emptying, increase satiety hyperglycemia that typically
develops in the early morning a ter
Meglitinides Nateglinide (Starlix) Stimulate insulin secretion rom an overnight ast o at least eight
Repaglinide (Prandin) pancreatic beta cells hours.
w : morning
Sodium-glucose Canagli lozin (Invokana) Inhibit glucose reabsorption in the kidneys, hyperglycemia that is caused by the
cotransporter 2 (SGLT2) Dapagli lozin (Farxiga) thereby increasing urinary early-morning release o growth
inhibitors glucose excretion hormone, which reduces insulin
Empagli lozin (Jardiance)
sensitivity.
Sul onylureas Glipizide (Glucotrol) Stimulate insulin secretion rom pancreatic :
Glyburide (Diabeta) beta cells hyperglycemia that results rom
the release o counterregulatory
Thiazolidinediones Pioglitazone (Actos) Increase insulin sensitivity hormones ollowing nighttime
hypoglycemia; also called the
Rosiglitazone (Avandia) Somogyi effect.

Bo 20-10 Diet-Drug Interactions
Check this table or notable nutrition-related e ects o the medications discussed in this chapter.
a - t g t t t t : Flatulence, abdominal cramps, diarrhea

m t t : May decrease blood concentrations o calcium and vitamin B 6
b (met ormin) g t t t t : Metallic taste, nausea, vomiting, anorexia, latulence, abdominal
cramps, diarrhea
d t t t : Excessive alcohol intake may cause lactic acidosis, which requires

emergency treatment
m t t : Decreased olate and vitamin B12 absorption, which may lead to de iciency
m t m t t : Hypoglycemia, weight gain
s g t t t t : Nausea, abdominal cramps, diarrhea, constipation
d t t t : Alcohol may delay drug absorption and prolong hypoglycemia (i
hypoglycemia occurs)
m t t : Hypoglycemia, weight gain, allergic skin reactions

T z m t t : Weight gain, luid retention, edema, anemia, decreased bone density and
increased risk o ractures (women)
Physical Activity and Diabetes Management

Regular physical activity can improve insulin sensitivity, muscle glucose uptake, and
overall glycemic control and is therefore a central feature of diabetes management.
Physical activity also benefits other aspects of health, including cardiovascular risk fac-
tors and body weight. Children with diabetes or prediabetes should engage in at least
60 minutes of aerobic activity each day. Adults with diabetes are advised to perform at
least 150 minutes of moderate-to-vigorous aerobic activity each week, spread over at
least three days of the week. Both children and adults should participate in two or three
sessions of muscle-strengthening exercises weekly.48
m e t e Before a person with diabetes begins a new exercise
program, a medical evaluation should screen for problems that may be aggravated by
certain activities. Complications involving the heart and blood vessels, eyes, kidneys, feet,
and nervous system may limit the types of activity recommended. For individuals with
a low level of fitness who have been relatively inactive, only mild or moderate exercise
may be prescribed at first; a short walk at a comfortable pace may be the first activity sug-
gested. People with severe retinopathy should avoid vigorous aerobic or resistance exer-
cise, which may lead to retinal detachment and damage to eye tissue. Individuals with
peripheral neuropathy should ensure that they wear proper footwear during exercise;
those with a foot injury or open sore should avoid weight-bearing activity.
m t g c t e Individuals who use insulin or med-
ications that increase insulin secretion must carefully adjust food intake and medica-
tion dosages to prevent hypoglycemia during physical activity. Medication dosages that
precede exercise often need to be reduced substantially. Blood glucose levels should be
checked both before and after an activity. If blood glucose is below 100 mg/dL, carbo-
hydrate should be consumed before the exercise begins.* Additional carbohydrate may
*As an example, about 15 grams of carbohydrate may be needed for 30 minutes of moderate-intensity exercise,
such as swimming or jogging.

be needed during or after prolonged activity or even several hours after the activity
is completed. Individuals with type 1 diabetes who have hyperglycemia and ketosis
should delay exercise until blood glucose falls below 250 mg/dL, as even mild exercise
may cause additional increases in blood glucose and ketone levels.49
Sick-Day Management
Illness, infection, or injury can cause hormonal changes that raise blood glucose levels
and increase the risk of developing diabetic ketoacidosis or the hyperosmolar hyper-
glycemic syndrome (see Box 20-11). During illness, individuals with diabetes should The nursing diagnosis risk for unstable
measure blood glucose and ketone levels several times daily. They should continue to blood glucose level may apply to an
use antidiabetic drugs, including insulin, as prescribed; adjustments in dosages may be individual with diabetes who has an
illness or injury.
necessary if they alter their diet or have persistent hyperglycemia. If appetite is poor,
patients should select easy-to-manage foods and beverages that provide the prescribed
amount of carbohydrate at each meal. To prevent dehydration, especially if vomiting
or diarrhea is present, patients should make sure they consume adequate amounts of
liquids throughout the day.
The Case Study in Box 20-12 provides an opportunity to review the treatment for
diabetes.
Review Notes
● Diabetes treatment includes nutrition therapy, the use o insulin and/or other antidiabetic
medications, and appropriate physical activity. Glycemic control is evaluated by monitoring
blood glucose levels and glycated hemoglobin.
● The quantity o carbohydrate consumed has the most signi icant in luence on blood glucose
levels a ter meals and is more important than the type o carbohydrate consumed.
● Carbohydrate counting is widely used in menu planning and can be taught at di erent levels
o complexity, depending on individual needs and abilities.
● Insulin therapy is required or patients who are unable to produce su icient insulin and may
be used in both type 1 and type 2 diabetes. Antidiabetic drugs prescribed or type 2 diabetes
improve hyperglycemia by various modes o action.
● Physical activity can improve glycemic control and enhance various aspects o general health.
Illness can worsen glycemic status and o ten requires medication adjustments.
Bo 20-12 C s Stud : Ch d w th T 1D t s
n 12- - who was diagnosed with type 1 diabetes two positive or ketones, and her blood glucose levels were 400 mg/dL. The
years ago. She practices intensive therapy and has had the support o her diagnosis was diabetic ketoacidosis.
parents and an excellent diabetes management team. With their help, Nora 1. Describe the metabolic events that lead to ketoacidosis. Were Nora’s
has been able to assume the bulk o the responsibility or her diabetes care symptoms and laboratory tests consistent with the diagnosis?
and has managed to control her blood glucose remarkably well. In the past
2. Review Table 20-3 on p. 574, and consider the advantages and disadvan-
ew months, however, Nora has been complaining bitterly about the imposi-
tages that intensive therapy might have or Nora. Describe the complica-
tions diabetes has placed on her li e and her interactions with riends.
tions associated with long-term diabetes.
Sometimes she re uses to monitor her blood glucose levels, and she has
skipped insulin injections a ew times. Recently, Nora was admitted to the 3. Discuss how Nora’s age might in luence her ability to cope with and man-
emergency room complaining o ever, nausea, vomiting, and intense thirst. age her diabetes. Why might she eel that diabetes is disrupting her li e?
The physician noted that Nora was con used and lethargic. A urine test was List suggestions that may help. How might you explain the importance o
glycemic control to a 12-year-old girl?

20.3 Diabetes Management in Pregnancy
Nursing diagnoses or diabetic
pregnancies may include risk for Women with diabetes face new challenges during pregnancy. Due to hormonal changes,
disturbed maternal-fetal dyad and pregnancy increases insulin resistance and the body’s need for insulin, so maintaining
risk for delayed development: fetal. glycemic control may be more difficult. In addition, 4 to 14 percent of nondiabetic
women in the United States develop gestational diabetes (the prevalence depends on
the patient population).50 Women with gestational diabetes are at greater risk of devel-
oping type 2 diabetes later in life, and their children are at increased risk of developing
BOx 20-14 obesity and type 2 diabetes as they enter adulthood.
A pregnancy complicated by diabetes increases health risks for both mother and
Goals or glycemic control in pregnant
women:
fetus (see Box 20-13). Uncontrolled diabetes is linked with increased incidences of
●
miscarriage, birth defects, and fetal deaths. Newborns are more likely to suffer from
Be ore meals: ,95 mg/dL
respiratory distress and to develop metabolic problems such as hypoglycemia, jaun-
●
1 hour a ter the start o a meal: dice, and hypocalcemia. Women with diabetes often deliver babies with
,140 mg/dL
(abnormally large bodies), which makes delivery more difficult and can result in
●
2 hours a ter the start o a meal: birth trauma or the need for a cesarean section. Macrosomia results because mater-
,120 mg/dL nal hyperglycemia induces excessive insulin production by the fetal pancreas, which
●
HbA1c : 6–6.5% stimulates growth and fat deposition.51 Box 20-14 shows the glycemic goals for preg-
nant women with diabetes.
Pregnancy in Type 1 or Type 2 Diabetes

Women with diabetes who achieve glycemic control at conception and during the first
trimester of their pregnancy substantially reduce the risks of birth defects and spon-
taneous abortion (see Photo 20-6). For this reason, women contemplating pregnancy
should receive preconception care to avoid complications that can result from uncon-
trolled diabetes. Maintaining glycemic control during the second and third trimesters
minimizes the risks of macrosomia and morbidity in newborn infants.
Women with type 1 diabetes require intensive insulin ther-
apy during pregnancy. Insulin adjustments may be necessary
Photo 20-6 Diabetic Pregnancy every few weeks due to changes in insulin sensitivity. Patients
with type 2 diabetes are usually switched from their usual med-
ications to insulin therapy to prevent possible toxicity to the
fetus.52 Although metformin and the sulfonylurea glyburide
may be safe to use at conception and during early pregnancy in
pregnant women with type 2 diabetes, research data are limited
in this population so physicians may be reluctant to prescribe
the drugs.53
ERproductions Ltd/Getty Images
Nutrient requirements during pregnancy are similar for

women with and without diabetes. In women with diabetes,
however, carbohydrate intakes must be balanced with insu-
lin treatment and physical activity to avoid hypoglycemia and
hyperglycemia. To help with this goal, women should consume
meals and snacks at similar times each day, and select carbohy-
drate sources that facilitate glucose control after meals, such as
Glycemic control during pregnancy o ers the best chance
o a sa e delivery and a healthy in ant.
whole grains, fruits, and vegetables. An evening snack is usu-
ally required to prevent overnight hypoglycemia and ketosis.
When insulin dosages are adjusted, the diabetic woman will
need to modify her carbohydrate intake as well.
(Mak-roh-SOH-mee-
ah): the condition o having
an abnormally large body; in Gestational Diabetes
in ants, re ers to birth weights Risk of gestational diabetes is highest in women who have a family history of diabetes,
o 4000 grams (8 pounds,
are obese, are in a high-risk ethnic group (for example, African American, Hispanic/
13 ounces) and above.
Latino, Native American, or Pacific Islander), or have previously given birth to an infant

Bo 20-15 C s Stud : W m w th T 2D t s
T c 41- - Mexican-American woman recently re ers Mrs. Cordova to a dietitian to help her with her weight-management
diagnosed with type 2 diabetes. Mrs. Cordova developed gestational goals.
diabetes while she was pregnant with her second child. Her blood 1. What actors in Mrs. Cordova’s medical history increase her risk or diabetes?
glucose levels returned to normal ollowing pregnancy, and she was Are her husband and children also at risk?
advised to get regular checkups, maintain a desirable weight, and engage
2. Describe the general characteristics o a diet and exercise program that would
in regular physical activity. Although she reports that she does not overeat
be appropriate or Mrs. Cordova. How might weight loss and physical activity
and that she exercises regularly, she has been unable to maintain a healthy
bene it her diabetes?
weight. At 5 eet 3 inches tall, Mrs. Cordova currently weighs 165 pounds.
She has decided to lose weight and join a gym because she is concerned 3. I Mrs. Cordova is unable to control her blood glucose with diet and physical
about the long-term e ects o diabetes and the possibility that she may activity, what treatment might be suggested? Explain to Mrs. Cordova why she
need insulin injections. She is also concerned about her husband and would probably not require insulin at this time.
children because they are overweight and not very active. The physician 4. What dietary and li estyle changes may help to prevent diabetes in
Mrs. Cordova’s husband and children?
weighing over 9 pounds. To ensure that appropriate treatment is offered, physicians

routinely test women for gestational diabetes between 24 and 28 weeks of gestation. In
high-risk women, testing may begin prior to pregnancy or soon after conception; note
that some women may be found to have undiagnosed type 2 diabetes at the earlier time
points. Even mild hyperglycemia can have adverse effects on a developing fetus and
may lead to complications during pregnancy.
Weight loss is not recommended during pregnancy. For women with gesta-
tional diabetes who are overweight or obese, a modest caloric reduction (about
30 percent less than the total energy requirement) may be recommended to slow
weight gain.54 Limiting the carbohydrate intake to less than 45 percent of total
energy intake may improve blood glucose levels after meals. Carbohydrate is usu-
ally poorly tolerated in the morning; therefore, restricting carbohydrate (to about
30 grams) at breakfast may be helpful. The remaining carbohydrate intake should
be spaced throughout the day in several meals and snacks, including an evening
snack to prevent ketosis during the night. Regular aerobic activity is recommended
because it can help to improve glycemic control. Women who fail to achieve gly-
cemic goals through diet and exercise alone may need to use insulin or an antidia-
betic drug that is safe to use during pregnancy (such as metformin or glyburide). 55
The Case Study in Box 20-15 reviews the connections between gestational diabetes
and type 2 diabetes.
Review Notes
● Care ul management o blood glucose levels be ore and during pregnancy may prevent
complications in mother and in ant. Women with diabetes who become pregnant may need to
adjust their insulin therapy or medications, consume meals and snacks at similar times each
day, and consume an evening snack to prevent overnight ketosis.
● Women with gestational diabetes may need to restrict energy and/or carbohydrate intakes to
maintain appropriate blood glucose levels; insulin or an antidiabetic drug may be prescribed
to help them maintain glycemic control.
Diabetes Management in Pregnancy 587

Nutrition Assessment Checklist or People with Diabetes
MeDiCal HiSTory ❍ Monitor blood glucose levels at home
Check the medical record to determine: ❍ Adjust insulin and diet to accommodate sick days
❍ Type of diabetes ❍ Use appropriate foods to treat hypoglycemia
❍ Duration of diabetes
❍ Acute and chronic complications
anTHropoMeTriC DaTa
❍ Conditions, including pregnancy, that may alter treatment
Take accurate baseline height and weight measurements as
a basis for:
MeDiCaTionS ❍ Appropriate energy intake
In people with preexisting diabetes who use antidiabetic ❍ Initial insulin therapy
drugs (including insulin), note: Periodically reassess height and weight in children and
❍ Type of medication weight in adults and pregnant women to ensure that the
❍ Administration schedule meal plan provides an appropriate energy intake.
Check for use of other medications, including:
❍ Medications that affect blood glucose levels laboraTory TeSTS
❍ Cholesterol- and triglyceride-lowering medications Monitor the success of diabetes treatment using these tests:
❍ Antihypertensive medications ❍ Blood lipid concentrations
❍ Blood or urinary ketones
DieTary inTake ❍ Glycated hemoglobin
To devise an acceptable meal plan and coordinate ❍ Urinary protein (albuminuria)
medications, obtain:
❍ An accurate and thorough record of food intake and meal pHySiCal SignS
patterns Look for physical signs of:
❍ An account of usual physical activities ❍ Dehydration, especially in older adults
At medical checkups, reassess the person’s ability to: ❍ Foot ulcers
❍ Maintain an appropriate carbohydrate intake ❍ Nerve damage
❍ Maintain an appropriate energy intake ❍ Vision problems
Sel Check
1. Which o the ollowing is characteristic o type 1 4. Long-term glycemic control is usually evaluated by:
diabetes? a. self-monitoring of blood glucose.
a. Abdominal obesity increases risk. b. testing urinary ketone levels.
b. The pancreas makes little or no insulin. c. measuring glycated hemoglobin.
c. It is the predominant form of diabetes. d. testing urinary protein levels (albuminuria).
d. It often arises during pregnancy.
5. Regarding dietary carbohydrate, a patient with diabetes
2. Which o the ollowing is true about type 2 diabetes? should be most concerned about:
a. It is usually an autoimmune disease. a. consuming an appropriate quantity of carbohydrate at
b. The pancreas makes little or no insulin. each meal or snack.
c. Diabetic ketoacidosis is a common complication. b. consuming the correct proportion of sugars, starches,
d. Chronic complications may develop before it is and fiber in meals.
diagnosed. c. avoiding added sugars and kcaloric sweeteners.
d. choosing meals with ideal proportions of protein,
3. Most chronic complications associated with diabetes carbohydrate, and fat.
result rom:
a. altered kidney function. 6. Which o the ollowing is true regarding the general use o
b. infections that deplete nutrient reserves. alcohol in diabetes?
c. weight gain and hypertension. a. A serving of alcohol is considered part of the
d. damage to blood vessels and nerves. carbohydrate allowance.

b. Alcohol contributes to hyperglycemia and should be b. a mixture of intermediate- and long-acting insulin
avoided completely. injected between meals.
c. Alcohol can cause hypoglycemia and should therefore c. multiple daily injections that supply basal insulin and
be consumed with food if patients use insulin or precise insulin doses at each meal and snack.
medications that stimulate insulin secretion. d. the use of both insulin and oral antidiabetic agents.
d. Patients can use alcohol in unlimited quantities unless
they are pregnant. 9. In a person who has previously maintained good glycemic
control, hyperglycemia can be precipitated by:
7. The most e ective meal-planning strategy or managing a. infections or illness.
diabetes is: b. chronic alcohol ingestion.
a. carbohydrate counting. c. undertreatment of hypoglycemia.
b. an eating plan based on food lists created for persons d. prolonged exercise.
with diabetes.
c. following menus and recipes provided by a registered 10. Which dietary adjustment may be help ul or women with
dietitian. gestational diabetes?
d. the approach that best helps the patient control blood a. Consuming most of the day’s carbohydrate allotment in
glucose levels. the morning.
b. Restricting carbohydrate to about 30 grams at breakfast.
8. A patient using intensive insulin therapy is likely to ollow a c. Avoiding food intake after dinner.
regimen that involves: d. Reducing energy intake to about 50 percent of the
a. twice-daily injections that combine short-, intermediate-, calculated requirement.
and long-acting insulin in each injection.
Answers: 1. b, 2.d, 3. d, 4. c, 5. a, 6. c, 7. d, 8. c, 9. a, 10. b
For more chapter resources visit www. . to access MindTap, a complete digital course.
Clinical Applications
1. Using the carbohydrate-counting method described in Box 20-8 on pp. 578–579, determine an appropriate carbohydrate intake
(in both grams and portions) or a man with type 2 diabetes who requires approximately 2600 kcalories daily. Assume he would
bene it rom a carbohydrate allowance that is 50 percent o his energy intake. Using in ormation rom Tables 20-4 and 20-5 on
p. 578, develop a one-day sample menu that is likely to meet his carbohydrate goals. Use the ood lists in Appendix C to ind
additional examples o oods to include in your menu.
2. A diabetes educator typically meets with patients who have a wide variety o problems, concerns, and abilities. What suggestions
can be o ered to patients who have the problems listed below?
● An 18-year-old college woman with type 1 diabetes has a date at an un amiliar restaurant and is uncertain how she will calculate
the correct dose o rapid-acting insulin be ore the meal.
● A 45-year-old man with an HbA1c value o 8.5 percent states that he is unable to improve his diet because his job keeps him busy
all day and his wi e handles the ood shopping and meal preparations.
● A 75-year-old man with type 2 diabetes has developed retinopathy and can no longer read the digital display on his blood
glucose monitor.
Notes
1. Centers for Disease Control and Prevention, National Diabetes Statistics 4. American Diabetes Association, Classification and diagnosis of diabetes:
Report, 2017: Estimates of Diabetes and its Burden in the United States Standards of medical care in diabetes—2018, 2018.
(Atlanta, GA: Centers for Disease Control and Prevention, U.S. 5. Centers for Disease Control and Prevention, 2017.
Department of Health and Human Services, 2017). 6. A. L. May, E. V. Kuklina, and P. W. Yoon, Prevalence of cardiovascular
2. Centers for Disease Control and Prevention, 2017. disease risk factors among U.S. adolescents, 1999–2008, Pediatrics 129
3. American Diabetes Association, Classification and diagnosis of diabetes: (2012): 1035–1041.
Standards of medical care in diabetes—2018, Diabetes Care 41 (2018): 7. A. Maitra, Endocrine system, in V. Kumar and coeditors, Robbins Basic
S13–S27. Pathology (Philadelphia: Elsevier, 2018), pp. 749–796.
Notes 589
8. J. Crandall and H. Shamoon, Diabetes mellitus, in L. Goldman and 31. A. B. Evert and coauthors, Nutrition therapy recommendations for the
A. I. Schafer, eds., Goldman-Cecil Medicine (Philadelphia: Saunders, 2016), management of adults with diabetes, Diabetes Care 37 (2014): S120–S143.
pp. 1527–1548. 32. J. MacLeod and coauthors, Academy of Nutrition and Dietetics nutrition
9. Maitra, 2018. practice guideline for type 1 and type 2 diabetes in adults: Nutrition
10. A. M. Kanaya and C. Vaisse, Obesity, in D. G. Gardner and D. Shoback, intervention evidence reviews and recommendations, Journal of the
eds., Greenspan’s Basic and Clinical Endocrinology (New York: McGraw- Academy of Nutrition and Dietetics 117 (2017): 1637–1658; Evert and
Hill/Lange, 2018), pp. 731–741; T. Ota, Chemokine systems link obesity coauthors, 2014.
to insulin resistance, Diabetes and Metabolism Journal 37 (2013): 33. MacLeod and coauthors, 2017; Evert and coauthors, 2014.
165–172. 34. Evert and coauthors, 2014.
11. Centers for Disease Control and Prevention, 2017. 35. Evert and coauthors, 2014.
12. J. E. von Oettingen and coauthors, Utility of diabetes-associated 36. American Diabetes Association, Lifestyle management: Standards of
autoantibodies for classification of new onset diabetes in children and medical care in diabetes—2018, 2018; MacLeod and coauthors, 2017.
adolescents, Pediatric Diabetes 17 (2016): 417–425; R. B. Lipton and 37. Evert and coauthors, 2014.
coauthors, Onset features and subsequent clinical evolution of childhood 38. Evert and coauthors, 2014.
diabetes over several years, Pediatric Diabetes 12 (2011): 326–334. 39. MacLeod and coauthors, 2017; Evert and coauthors, 2014.
13. E. J. Mayer-Davis and coauthors, Incidence trends of type 1 and type 2 40. Evert and coauthors, 2014.
diabetes among youths, 2002–2012, New England Journal of Medicine 376 41. M. S. N. Kennedy and U. Masharani, Pancreatic hormones and
(2017): 1419–1429. antidiabetic drugs, in B. G. Katzung, ed., Basic and Clinical Pharmacology
14. American Diabetes Association, Prevention or delay of type 2 diabetes: (New York: McGraw-Hill/Lange, 2018), pp. 747–771.
Standards of medical care in diabetes—2018, Diabetes Care 41 (2018): 42. American Diabetes Association, Pharmacologic approaches to glycemic
S51–S54. treatment: Standards of medical care in diabetes—2018, Diabetes Care 41
15. S. H. Ley and coauthors, Prevention and management of type 2 diabetes: (2018): S73–S85.
Dietary components and nutritional strategies, Lancet 383 (2014): 43. Kennedy and Masharani, 2018.
1999–2007. 44. S. E. Inzucchi and coauthors, Management of hyperglycemia in type 2
16. Crandall and Shamoon, 2016. diabetes, 2015: A patient-centered approach, Diabetes Care 38 (2015):
17. U. Masharani and M. S. German, Pancreatic hormones and diabetes 140–149.
mellitus, in D. G. Gardner and D. Shoback, eds., Greenspan’s Basic 45. American Diabetes Association, Glycemic targets: Standards of medical
and Clinical Endocrinology (New York: McGraw-Hill/Lange, 2018), care in diabetes—2018, 2018.
pp. 595–682. 46. C. Boucher-Berry, E. A. Parton, and R. Alemzadeh, Excess weight gain
18. Crandall and Shamoon, 2016. during insulin pump therapy is associated with higher basal insulin doses,
19. D. G. Gardner, Endocrine emergencies, in D. G. Gardner and D. Shoback, Journal of Diabetes and Metabolic Disorders 15 (2016): 47; R. J. Brown and
eds., Greenspan’s Basic and Clinical Endocrinology (New York: McGraw- coauthors, Uncoupling intensive insulin therapy from weight gain and
Hill/Lange, 2018), pp. 783–807. hypoglycemia in type 1 diabetes, Diabetes Technology and Therapeutics 13
20. Crandall and Shamoon, 2016. (2011): 457–460.
21. Maitra, 2018. 47. Masharani and German, 2018.
22. Maitra, 2018. 48. American Diabetes Association, Lifestyle management: Standards of
23. C. J. White, Atherosclerotic peripheral arterial disease, in L. Goldman and medical care in diabetes—2018, 2018; MacLeod and coauthors, 2017.
A. I. Schafer, eds., Goldman-Cecil Medicine (Philadelphia: Saunders, 2016), 49. S. R. Colberg and coauthors, Physical activity/exercise and diabetes: A
pp. 497–504. position statement of the American Diabetes Association, Diabetes Care
24. Maitra, 2018. 39 (2016): 2065–2079.
25. Maitra, 2018. 50. K. Rosene-Montella, Common medical problems in pregnancy, in
26. Masharani and German, 2018; Crandall and Shamoon, 2016. L. Goldman and A. I. Schafer, eds., Goldman-Cecil Medicine (Philadelphia:
27. American Diabetes Association, Implications of the United Kingdom Saunders, 2016), pp. 1610–1623.
Prospective Diabetes Study, Diabetes Care 25 (2002): S28–S32; Diabetes 51. Masharani and German, 2018.
Control and Complications Trial Research Group, The effect of intensive 52. American Diabetes Association, Management of diabetes in pregnancy:
treatment of diabetes on the development and progression of long-term Standards of medical care in diabetes—2018, Diabetes Care 41 (2018):
complications in insulindependent diabetes mellitus, New England Journal S137–S143.
of Medicine 329 (1993): 977–986. 53. Masharani and German, 2018; R. I. Holt and K. D. Lambert, Use of
28. American Diabetes Association, Glycemic targets: Standards of medical oral hypoglycaemic agents in pregnancy, Diabetic Medicine 31 (2014):
care in diabetes—2018, Diabetes Care 41 (2018): S55–S64. 282–291.
29. American Diabetes Association, Lifestyle management: Standards of 54. Academy of Nutrition and Dietetics, Nutrition Care Manual (Chicago:
medical care in diabetes—2018, Diabetes Care 41 (2018): S38–S50. Academy of Nutrition and Dietetics, 2018).
30. American Diabetes Association, Lifestyle management: Standards of 55. American Diabetes Association, Management of diabetes in pregnancy:
medical care in diabetes—2018, 2018. Standards of medical care in diabetes—2018, 2018.

20.4 Nutrition in Practice
The Metabolic Syndrome
Chapter 20 described how insulin resistance—a reduced States, with an overall prevalence of nearly 35 percent
sensitivity to insulin in muscle, adipose, and liver cells— (see Figure NP20-1). 2
can contribute to hyperglycemia and hyperinsulinemia Because the disorders that identify the metabolic syn-
and, eventually, to type 2 diabetes. Insulin resistance is drome are considered independent risk factors for heart
also a central feature of several other conditions, includ- disease or diabetes, some medical experts have questioned
ing the m t bo i y d om , a cluster of metabolic abnor- whether the diagnosis of metabolic syndrome is a useful
malities that are associated with an increased risk of one.3 The main benefit of grouping the disorders may be to
developing cardiovascular diseases (CVD) and type 2
diabetes. This Nutrition in Practice describes how the
metabolic syndrome is diagnosed, how and why it might
TABLE NP20-1 Features of the Metabolic
develop, its potential consequences, and current treat-
ment approaches. Box NP20-1 defines the relevant terms. Syndrome
The metabolic syndrome is diagnosed when three or more of the
How is the metabolic syndrome diagnosed, following abnormalities are present.
and how common is it in the United States? Measure reference Value
Table NP20-1 lists the laboratory values used to identify
Hyperglycemia Fasting plasma glucose >100 mg/dL, or
the metabolic syndrome, which is diagnosed when at least undergoing drug treatment for elevated
three of the following disorders are present: hyperglyce- glucose
mia, abdominal obesity, hyp t ig y id mi (elevated
blood triglyceride levels), reduced high-density lipopro- Abdominal obesity Waist circumference .40" in men,
tein (HDL) cholesterol levels, and hypertension (high .35" in women
blood pressure). Although published values vary, an esti- Hypertriglyceridemia VLDLs $150 mg/dL, or undergoing drug
mated 23 percent of adults in the United States may meet treatment for elevated triglycerides
the criteria for the metabolic syndrome.1 Prevalence of
the metabolic syndrome greatly increases with age, rang- Reduced HDL HDLs ,40 mg/dL in men, ,50 mg/dL
ing from about 18 percent in people who are 20 to 39 cholesterol in women
years old to about 53 percent in those who are 60 years Hypertension Blood pressure $130/85 mm Hg,
old or older. In addition, risk varies according to ethnic- or undergoing drug treatment for
ity and gender: Mexican-American men have the high- hypertension
est incidence of the metabolic syndrome in the United
Box NP20-1 Glossary
dipo ti (AH-dih-poe-NECK-tin): a hormone produced by m t bo i y d om : a cluster of interrelated disorders, including

adipose cells that promotes insulin sensitivity. abdominal obesity, insulin resistance, high blood pressure,
ytoki (SIGH-toe-kines): signaling proteins produced by the and abnormal blood lipids, which together increase the risk
body’s cells; many cytokines are produced by immune cells and of diabetes and cardiovascular disease; also known as insulin
regulate immune responses. resistance syndrome or syndrome X.
ib i og (fye-BRIN-oh-jen): a liver protein that promotes blood p mi og tiv to i hibito -1: a protein that promotes blood
clot formation. clotting by inhibiting blood clot degradation within blood
hyp t ig y id mi : elevated blood triglyceride levels. Blood vessels.
triglycerides are transported in very-low-density lipoproteins i ti (re-ZIST-in): a hormone produced by adipose cells that
(VLDL). promotes insulin resistance.
The Metabolic Syndrome 591

FIGURE NP20-1 Prevalence of the Metabolic of t , an adipocyte hormone that promotes insu-
Syndrome in the U.S. Population lin sensitivity and glucose tolerance. Conversely, the adi-
pose cells release larger amounts of the hormone t ,
which promotes insulin resistance. Enlarged adipose
cells also activate local macrophages (immune cells),
Percent of Population (%)
which secrete a number of t k (signaling proteins)

that induce inflammation; the inflammatory process
leads to multiple metabolic changes that reduce insulin
responsiveness.8
Can obesity lead to other problems related

to the metabolic syndrome?
Abdominal obesity is frequently associated with blood
lipid abnormalities. Because the insulin-resistant adi-
White African Mexican pose cells release more fatty acids into the blood, the liver
American American must accelerate its production of very-low-density lipo-
Source: E. J. Benjamin and coauthors, Heart disease and stroke
proteins (VLDL), and hypertriglyceridemia develops.9
statistics—2017 update: A report rom the American Heart Association, At the same time, insulin resistance hinders the ability
Circulation 135 (2017): e146–e603. of adipose cells to extract and store triglycerides from
chylomicrons and VLDL. Excessive body fatness is also
associated with elevated low-density lipoprotein (LDL)
cholesterol levels and reduced HDL levels.
guide clinical management of these interrelated metabolic Several mechanisms may play a role in promoting the
problems.4 In addition, some studies indicate that heart hypertension associated with obesity.10 The hyperinsuline-
disease risk actually varies substantially among individu- mia that typically accompanies obesity promotes sodium
als with the metabolic syndrome, suggesting that further reabsorption in the kidneys, resulting in fluid retention
screening is needed to identify those who would benefit and an expanded blood volume. Elevated fatty acid levels
from aggressive treatment.5 may lead to increased vasoconstriction and reduced vaso-
relaxation. Some obese individuals have increased sym-
What causes the metabolic syndrome? pathetic nervous system activity, which could contribute
Both genetic and environmental factors probably con- to hypertension. Finally, adipocytes produce angioten-
tribute to the development of the metabolic syndrome. sinogen, a precursor of the vasoconstrictor angiotensin II,
However, the close relationship between abdominal obe- which raises blood pressure.
sity and insulin resistance suggests that the current obe-
sity crisis in the United States may be largely responsible How does the metabolic syndrome
for its high prevalence. Visceral fat is thought to induce contribute to cardiovascular disease risk?
a number of metabolic changes that promote insulin The disorders that characterize the metabolic syndrome—
resistance, which then leads to hyperglycemia and other obesity, lipid abnormalities, and hypertension—are all
abnormalities. independent risk factors for CVD. In addition, the con-
dition is often associated with blood vessel dysfunction
How does obesity lead to insulin resistance? and the tendency to form blood clots, characteristics
Various theories have been proposed to explain the rela- that favor the development of atherosclerosis and raise
tionship between obesity and insulin resistance. The the risk of heart attack or stroke. For example, individu-
enlarged adipose cells of obese individuals have a limited als with the metabolic syndrome exhibit reduced pro-
capacity to store triglyceride. Instead, these cells increase duction of the vasodilator nitric oxide and increased
their release of fatty acids into the bloodstream, result- secretion of the vasoconstrictor endothelin-1—changes
ing in the abnormal accumulation of triglycerides in the that enhance vasoconstriction and stimulate the release
muscle, liver, and other tissues; the high fat content of of pro-inflammatory cytokines. These cytokines release
these tissues may alter cellular responses to insulin that factors that increase endothelial permeability, recruit
lead to insulin resistance. 6 In addition, enlarged adipose immune cells, and increase oxidative stress, thereby
cells alter the hormones and proteins they release into promoting atherosclerosis. Inflammation of endothe-
the blood, promoting a state of insulin resistance.7 For lial tissue, obesity, and insulin resistance may all pro-
example, obesity is associated with the reduced secretion mote the increased production of procoagulant proteins

such as and t t t -1 .11 Photo NP20-1
Individuals with the metabolic syndrome are also at
increased risk of developing diabetes, which is another
major risk factor for CVD.
What is the usual treatment for the

metabolic syndrome?
The usual treatment goals for the metabolic syndrome are
to correct the abnormalities that increase CVD and dia-
betes risk. In most individuals, a combination of weight
loss and physical activity can improve insulin resistance,
blood pressure, and blood lipid levels.12 Even a moderate
weight loss (7 to 10 percent of body weight) can improve
the abnormalities, although many people find this dif-
ficult to achieve. Additional dietary strategies depend
on a patient’s specific problems. If dietary and lifestyle
modifications are not successful, medications may be
prescribed. Because effective treatment requires lifelong
Rolf Bruderer/Flir t/Corbis

commitment, health care providers should work with
patients to develop a treatment plan that they are willing
to adopt.
What dietary strategies, other than weight

loss, are suggested for people with the
Regular exercise can reduce the risks
metabolic syndrome? o developing the metabolic syndrome,
cardiovascular diseases, and type 2 diabetes.
In individuals with hypertriglyceridemia, the general
recommendations are to reduce intakes of added sug-
ars and refined grain products (sugar-sweetened bever-
ages, juices, white bread, sweetened cereal, and desserts) although longer periods (one hour daily) are recommended
and increase servings of whole grains and foods high in for weight control.15 Resistance exercise, using free weights
fiber (whole-wheat bread, oatmeal, legumes, fruits, and or weight machines, is beneficial for improving insulin sen-
vegetables).13 In some people, carbohydrate restriction sitivity and should be performed at least twice weekly. A
may help to reduce blood triglyceride levels and improve sedentary lifestyle can worsen the progression of metabolic
hyperglycemia. Including fish in the diet each week syndrome and should be discouraged.
may also improve triglyceride levels. Individuals with
hypertension are encouraged to reduce sodium intake What types of medications are used to treat
and increase consumption of fruits and vegetables and the metabolic syndrome?
low-fat milk products. A diet low in saturated and trans If dietary and lifestyle changes are unsuccessful, medica-
fats can help to reduce LDL cholesterol levels. Chapter tions may be prescribed to correct hypertriglyceridemia
21 describes additional dietary modifications that may and hypertension (Chapter 21 provides details). At pres-
reduce CVD risk. ent, antidiabetic drugs are not routinely used to treat insu-
lin resistance in patients with the metabolic syndrome
Why is physical activity recommended for due to insufficient evidence that the drugs can improve
people with the metabolic syndrome? long-term outcomes better than lifestyle changes.
Regular physical activity helps with weight management As explained in this Nutrition in Practice, the metabolic
and may also improve blood lipid concentrations, hyper- syndrome consists of a cluster of interrelated disorders
tension, and insulin resistance—all changes that can reduce that may increase the risk of developing CVD and type
the risk of developing CVD.14 A regular exercise program 2 diabetes. Whereas most of the features of the meta-
can also prevent or delay the onset of diabetes in persons bolic syndrome are individual risk factors for CVD, in
at risk (see Photo NP20-1). About 150 minutes per week combination they may raise risk twofold to threefold.
(about 30 minutes of activity on five days of the week) of Treatment of the metabolic syndrome emphasizes dietary
moderate-intensity aerobic activity is often suggested, and lifestyle changes.
The Metabolic Syndrome 593

Notes
1. E. Benjamin and coauthors, Heart disease and stroke statistics—2017 8. Masharani and German, 2018.
update: A report from the American Heart Association, Circulation 135 9. D. N. Reeds, Metabolic syndrome: Definition, relationship with insulin
(2017): e146–e603. resistance, and clinical utility, in A. C. Ross and coeditors, Modern
2. Benjamin and coauthors, 2017. Nutrition in Health and Disease (Baltimore: Lippincott Williams & Wilkins,
3. A. M. Kanaya and C. Vaisse, Obesity, in D. G. Gardner and D. Shoback, 2014), pp. 828–836.
eds., Greenspan’s Basic and Clinical Endocrinology (New York: McGraw- 10. M. D. Jensen, Obesity, in L. Goldman and A. I. Schafer, eds., Goldman-
Hill/Lange, 2018), pp. 731–741; S. N. Magge, E. Goodman, and S. C. Cecil Medicine (Philadelphia: Saunders, 2016): 1458–1466.
Armstrong, The metabolic syndrome in children and adolescents: Shifting 11. E. Kassi and coauthors, Metabolic syndrome: Definitions and controversies,
the focus to cardiometabolic risk factor clustering, American Academy of BMC Medicine 9 (May 5, 2011): doi: 10.1186/1741-7015-9-48.
Pediatrics 140 (2017): doi: 10.1542/peds.2017-1603. 12. Academy of Nutrition and Dietetics, Nutrition Care Manual (Chicago:
4. U. Masharani and M. S. German, Pancreatic hormones and diabetes Academy of Nutrition and Dietetics, 2018).
mellitus, in D. G. Gardner and D. Shoback, eds., Greenspan’s Basic 13. L. Berglund and coauthors, Evaluation and treatment of
and Clinical Endocrinology (New York: McGraw-Hill/Lange, 2018), hypertriglyceridemia, Journal of Clinical Endocrinology and Metabolism
pp. 595–682. 97 (2012): 2969–2989; M. Miller and coauthors, Triglycerides and
5. S. Malik and coauthors, Impact of subclinical atherosclerosis on cardiovascular disease: A scientific statement from the American Heart
cardiovascular disease events in individuals with metabolic syndrome and Association, Circulation 123 (2011): 2292–2333.
diabetes, Diabetes Care 34 (2011): 2285–2290. 14. B. Strasser, Physical activity in obesity and metabolic syndrome, Annals of
6. Masharani and German, 2018. the New York Academy of Sciences 1281 (2013): 141–159.
7. Kanaya and Vaisse, 2018. 15. Academy of Nutrition and Dietetics, 2018.

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Nutrition and Diabetes

20.1 Overview of Diabetes Mellitus

20.2 Treatment of Diabetes Mellitus

20.3 Diabetes Management in Pregnancy

20.4 Nutrition in Practice: Metabolic Syndrome

Gravity Images/Getty Images

Bo 20-1 Glossary of Diabetes-Related Symptoms and Complications

566 CHAPTER 20 Nutrition and Diabetes Mellitus

Diagnosis of Diabetes Mellitus BOx 20-2 Nursing Diagnosis

Overview of Diabetes Mellitus 567

a t ,30 years .40 yearsa

i t Little or none Varies; may be normal, increased, or decreased

r q t t All cases Some cases

f Juvenile-onset diabetes Adult-onset diabetes

type 1 diabetes often have a genetic susceptibility for the

T 2d t T 2 t is the most prevalent form of diabetes, accounting

568 CHAPTER 20 Nutrition and Diabetes Mellitus

T 2d t c a t Although most cases of type 2 dia-

Prevention of Type 2 Diabetes Mellitus

Acute Complications of Diabetes Mellitus

Overview of Diabetes Mellitus 569

Glycogen Glucose Triglyceride Triglyceride Protein Protein

Hyperglycemia Blood fatty Muscle Blood

Glycosuria Blood Fatty acid VLDLa Weight loss Glucose

Polyuria, Ketone Hypertriglyceridemia Aggravation of

Polydipsia Nervous Ketoacidosis

d t K t T 1d t A severe lack of insulin causes diabetic keto-

570 CHAPTER 20 Nutrition and Diabetes Mellitus

Chronic Complications of Diabetes Mellitus

Overview of Diabetes Mellitus 571

m c t Long-term diabetes is associated with detri-

basement membranes, growth of fibrous tissue (scarring), increased capillary

572 CHAPTER 20 Nutrition and Diabetes Mellitus

20.2 Treatment of Diabetes Mellitus

Treatment of Diabetes Mellitus 573

i One or two daily injections; Three or more daily injections or use o an

a t Fewer incidences o severe Delayed progression o retinopathy,

d t More rapid progression o Two old to three old increase in severe

Evaluating Diabetes Treatment

574 CHAPTER 20 Nutrition and Diabetes Mellitus

K t T t Ketone testing, which checks for the development of ketoacidosis,

m t l -T c t Individuals with diabetes are routinely mon-

Nutrition Therapy: Dietary Recommendations

T t c t i t k The amount of carbohydrate consumed has the greatest

Treatment of Diabetes Mellitus 575

W g f Recommendations for whole grain and fiber intakes are

d t f t A Mediterranean-style dietary pattern that emphasizes unsaturated fats

576 CHAPTER 20 Nutrition and Diabetes Mellitus

m t t Micronutrient recommendations for people with diabetes are the

e b W t T 2d t Because excessive body fat can worsen

Nutrition Therapy: Meal-Planning Strategies

c t c t Carbohydrate-counting techniques are simpler and more

Treatment of Diabetes Mellitus 577

578 CHAPTER 20 Nutrition and Diabetes Mellitus

FIGURE 20-2 Translating Carbohydrate Portions into a Day’s Meals

Carbohydrate goal 4 portions or 60 g Carbohydrate goal 2 portions or 30 g

Carbohydrate goal 5 portions or 75 g

Carbohydrate goal 4 portions or 60 g

Carbohydrate goal 2 portions or 30 g

f l t d t A meal-planning system originally developed for persons

Treatment of Diabetes Mellitus 579

i p t The forms of insulin that are commercially available differ by

i d Insulin is most often administered by t injection, either