Diabetes Management

NURS3018
 Objectives

At the end of this presentation students will be able to:

 Describe the types of treatment options for DM
clients
 Describe the current WHO recommendations for
dietary management of DM clients
 Management of DM
 The major components of the treatment of diabetes
are:

• Diet and Exercise

A
• Oral hypoglycaemic therapy
B
• Insulin Therapy
C
 A. Diet

 Diet is a basic part of management in every case.

Treatment cannot be effective unless adequate
attention is given to ensuring appropriate nutrition.

 Dietary treatment should aim at:

◦ ensuring weight control
◦ providing nutritional requirements
◦ allowing good glycaemic control with blood glucose levels as
close to normal as possible
◦ correcting any associated blood lipid abnormalities
 A. Diet (cont.)
The following principles are recommended as dietary guidelines
for people with diabetes:

 Dietary fat should provide 25-35% of total intake of calories but

saturated fat intake should not exceed 10% of total energy. Cholesterol
consumption should be restricted and limited to 300 mg or less daily.

 Protein intake can range between 10-30% total energy (0.6-0.8 g/kg of
desirable body weight). Requirements increase for children and during
pregnancy. Protein should be derived from both animal and vegetable
sources.

 Carbohydrates provide 45-60% of total caloric content of the diet.

Carbohydrates should be complex and high in fibre.

 Excessive salt intake is to be avoided. It should be particularly restricted

in people with hypertension and those with nephropathy.
 Exercise

 Physical activity promotes weight reduction and

improves insulin sensitivity, thus lowering blood glucose
levels.

 Together with dietary treatment, a programme of

regular physical activity and exercise should be
considered for each person. Such a programme must be
tailored to the individual’s health status and fitness.

 People should, however, be educated about the potential

risk of hypoglycaemia and how to avoid it.
 B. Oral Anti-Diabetic Agents

 There are currently four classes of oral anti-diabetic

agents:

i. Biguanides
ii. Insulin Secretagogues – Sulphonylureas
iii. Insulin Secretagogues – Non-sulphonylureas
iv. α-glucosidase inhibitors
v. Thiazolidinediones (TZDs)
 B.1 Oral Agent Monotherapy

 If glycaemic control is not achieved (HbA1c > 6.5%

and/or; FPG > 7.0 mmol/L or; RPG >11.0mmol/L)
with lifestyle modification within 1 –3 months, ORAL
ANTI-DIABETIC AGENT should be initiated.

 In the presence of marked hyperglycaemia in newly

diagnosed symptomatic type 2 diabetes (HbA1c > 8%,
FPG > 11.1 mmol/L, or RPG > 14 mmol/L), oral anti-
diabetic agents can be considered at the outset
together with lifestyle modification.
 B.1 Oral Agent Monotherapy (cont.)

As first line therapy:

 Obese type 2 patients, consider use of metformin, acarbose or TZD.

 Non-obese type 2 patients, consider the use of metformin or insulin

secretagogues

 Metformin is the drug of choice in overweight/obese patients.

TZDs and acarbose are acceptable alternatives in those who are
intolerant to metformin.

 If monotherapy fails, a combination of TZDs, acarbose and

metformin is recommended. If targets are still not achieved, insulin
secretagogues may be added
 B.2 Combination Oral Agents

Combination oral agents is indicated in:

 Newly diagnosed symptomatic patients with HbA1c

>10

 Patients who are not reaching targets after 3 months

on monotherapy
B.3 Combination Oral Agents and Insulin
 If targets have not been reached after optimal dose of
combination therapy for 3 months, consider adding
intermediate-acting/long-acting insulin (BIDS).

 Combination of insulin+ oral anti-diabetic agents (BIDS) has

been shown to improve glycaemic control in those not achieving
target despite maximal combination oral anti-diabetic agents.

 Combining insulin and the following oral anti-diabetic agents

has been shown to be effective in people with type 2 diabetes:
◦ Biguanide (metformin)
◦ Insulin secretagogues (sulphonylureas)
◦ Insulin sensitizers (TZDs)(the combination of a TZD plus insulin is not an
approved indication)
◦ α-glucosidase inhibitor (acarbose)

 Insulin dose can be increased until target FPG is achieved.

 Diabetes
Management
Algorithm
Oral Hypoglycaemic Medications
 General Guidelines for Use of Oral Anti-Diabetic Agent in
Diabetes

 In elderly non-obese patients, short acting insulin secretagogues can be

started but long acting Sulphonylureas are to be avoided. Renal function
should be monitored.

 Oral anti-diabetic agent s are not recommended for diabetes in pregnancy

 Oral anti-diabetic agents are usually not the first line therapy in diabetes
diagnosed during stress, such as infections. Insulin therapy is recommended
for both the above

 Targets for control are applicable for all age groups. However, in patients
with co-morbidities, targets are individualized

 When indicated, start with a minimal dose of oral anti-diabetic agent, while
reemphasizing diet and physical activity. An appropriate duration of time
(2-16 weeks depending on agents used) between increments should be given
to allow achievement of steady state blood glucose control
 C. Insulin Therapy
Short-term use:
 Acute illness, surgery, stress and emergencies
 Pregnancy
 Breast-feeding
 Insulin may be used as initial therapy in type 2 diabetes in marked
hyperglycaemia
 Severe metabolic decompensation (diabetic ketoacidosis,
hyperosmolar nonketotic coma, lactic acidosis, severe
hypertriglyceridaemia)

Long-term use:
 If targets have not been reached after optimal dose of combination
therapy or BIDS, consider change to multi-dose insulin therapy.
When initiating this, insulin secretagogues should be stopped and
insulin sensitisers e.g. Metformin or TZDs, can be continued.
 Insulin regimens
 The majority of patients will require more than one daily injection if good
glycaemic control is to be achieved. However, a once-daily injection of an
intermediate acting preparation may be effectively used in some
patients.

 Twice-daily mixtures of short- and intermediate-acting insulin is a commonly

used regimen.

 In some cases, a mixture of short- and intermediate-acting insulin

may be given in the morning. Further doses of short-acting insulin are
given before lunch and the evening meal and an evening dose of
intermediate-acting insulin is given at bedtime.

 Other regimens based on the same principles may be used.

 A regimen of multiple injections of short-acting insulin before the main

meals, with an appropriate dose of an intermediate-acting insulin given at
bedtime, may be used, particularly when strict glycaemic control is
mandatory.
Overview of Insulin and Action
 Screening for Diabetes

Fasting Blood Significance Actions

Glucose (g/dl)

<110 Normal Retest in 3 Years

> 100 & < 126 IGT 1. Additional testing

2. Check for risk factors
3. MNT (Medical Nutrition
Therapy)
>126 Diabetes Likely 1. Confirm by 2nd FBG
2. Treat DM
 Units of Blood Glucose

• Blood sugar (also

called blood glucose)
needs to be tightly
controlled in the
human body to
minimise the risk of
complications
developing.

• Formula to calculate
mmol/l from mg/dl:
mmol/l = mg/dl / 18.

• Formula to calculate
mg/dl from mmol/l:
mg/dl = 18 × mmol/l.
 Management of Diabetes Mellitus

 Nutrition
 Blood glucose monitoring
 Medications
 Physical activity/exercise
 Behavior modification
 Medical Nutrition Therapy

 Primary Goal – improve metabolic

control
 Blood glucose
 Lipid (cholesterol) levels
 Medical Nutrition Therapy

 Maintain short and long term body weight

 Reach and maintain normal growth and
development
 Prevent or treat complications
 Improve and maintain nutritional status
 Provide optimal nutrition for pregnancy
Nutritional Management for Type I Diabetes

 Consistency and timing of meals

 Timing of insulin

 Monitor blood glucose regularly

 Nutritional Management for Type II Diabetes

 Weight loss
 Smaller meals and snacks
 Physical activity
 Monitor blood glucose and medications
 Diabetes Control and Complications Trial

 10 year randomized, controlled, clinical trial

 Determine the effects of glucose control on the
development of long term microvascular and
neurologic complications in persons with type I
diabetes.
 1441 participants, ages 13 to 39
 Microvascular complications (retinopathy,
nephropathy, and neuropathy) affect hundreds of
millions of patients with type 2 and type 1 diabetes
 (Valencia, & Florez, 2017)
 Diabetes Control and Complications Trial

 Conventional therapy:
 1 - 2 insulin injections,
 self monitoring B.G.
 routine contact with MD and case manager 4X/year.

 Intensive therapy:
 3 or more insulin injections, with adjustments in dose according to
B.G monitoring,
 planned dietary intake and anticipated exercise.
 Diabetes Control and Complications

 Results of Diabetes control include:

 76% reduction in retinopathy
 60% reduction in neuropathy
 54% reduction in albuminuria
 39% reduction in microalbuminuria

 Implication: Improved blood glucose control also

applies to person with type II diabetes.
 Nutrition Recommendations

 Carbohydrate
 60-70% calories from carbohydrates and monounsaturated
fats as well as PUFAS

 Protein
 10-20% total calories
 Nutrition Recommendations

 Fat
 <10% calories from saturated fat
 10% calories from PUFA
 <300 mg cholesterol

 Fiber
 20-35 grams/day

 Alcohol
 Type I – limit to 2 drinks/day, with meals
 Type II – substitute for fat calories
 2003 Diabetic Exchange Lists

Food Group CHO Protein Fat Calories

(grams) (grams) (grams)

Starch 15 3 0-1 80

Fruit 15 60

Milk
Skim 12 8 0-3 90
Low-Fat 12 8 5 120
Whole 12 8 8 150

Other 15 varies varies Varies

Carbohydrate

Nonstarchy 5 2 0 25
Vegetables
 2003 Diabetic Exchange Lists

Food CHO Protein Fat Calories

Group (grams) (grams)
Meat
Very Lean 7 0-1 35
Lean 7 3 55
Medium 7 5 75
Fat 7 8 100
High Fat

Fat 5 45
 2003 Diabetic Exchange Lists

 Carbohydrate Exchanges – 3 g protein, 0-1 g fat and

80 calories
 Bread: bagel, bread, English muffin, tortilla
 Cereal: cold and hot cereal, pasta, rice
 Starchy vegetables: corn, peas, potato, squash
 Crackers and snacks
 Dried beans
 Starch prepared foods with fat: biscuits, muffins
 2003 Diabetic Exchange Lists

 Fruit Exchanges
 15 grams carbohydrate and 60 calories

 Fruit and fruit juice

 Vegetables
 5 g carbohydrate, 2g protein and 25 calories
 2003 Diabetic Exchange Lists

 Other Carbohydrates
 Exchanges and Serving size vary

 Angel food cake – 2 carbohydrates

 Cake, frosted – 2 carbohydrates, 1 fat

 Donut, plain cake - 1 ½ carbohydrates, 2 fats

 Potato chips – 1 carbohydrate, 2 fats

 2003 Diabetic Exchange Lists

 Milk – 12 g carbohydrate, 8 g protein and 0-8 g fat

 Meat and Meat Substitutes
 Very Lean Meat (7 g protein, 0-1 g fat and 35
calories)
 Chicken, turkey – white meat
 Shellfish (clams, crab, lobster, shrimp)
 2003 Diabetic Exchange Lists

 Lean Meat (7 g protein, 3 g fat and 55 calories)

 Select or choice beef, trimmed of fat

 Lean pork

 Poultry, turkey –dark meat

 2003 Diabetic Exchange Lists

 Medium Fat Meat (7 g protein, 5 g fat and 75 calories)

 Most beef products – corned beef, ribs, prime grades
 Ground turkey
 Chicken – dark meat with skin

 High Fat Meat (7 g protein, 8 g fat and 75 calories)

 All cheeses
 Processed meats, hot dogs
 Carbohydrate Counting

 A serving of carbohydrate is considered 15 grams

 A serving of fruit or starch or 3 servings of vegetable
is = to 1 carbohydrate
 One milk serving is considered equal to one
carbohydrate
 Food Labeling in DM Management

 Apart from general healthy eating advice, people

with diabetes need to be aware of their daily intake of
carbohydrates, including sugars.
 The amount of foods, particularly carbohydrates
(including sugars), eaten by people with diabetes
during mealtime should be matched with
 their diabetic conditions
 medications

 and daily living needs

 and kept consistent on a day-to-day basis for
stabilizing blood glucose level.
 Food Labeling in DM Management

 People with diabetes should discuss their diabetic

meal plans with a dietician or healthcare professional,
then make use of nutrition labels for choosing
appropriate pre-packaged foods.

 A person with diabetes should not follow other

people’s meal plans.
What Kinds of Food Contain Carbohydrates?

 Cereals (Starch)
 Root vegetables (Starch)
 Legumes (Starch)
 Dairy (Lactose)
 Fruits (Fructose)
 Sugars and Sugary food (Sucrose)
Diabetes and Nutrition Labeling

 Using nutrition label can

help people with diabetes
to understand and find
out the carbohydrate
contents (including
sugars) in food products
for meeting the needs of
the personal meal plan.
Important principles in labels and DM
 Three Simple Steps to
Read Nutrition Label

Step 1
 Take note of the reference amount of food being
used in the nutrition label
Step 2
 Read the energy and nutrient content together
with the reference amount
Step 3
 Refer to the percentage Nutrient Reference Value
(%NRV), if available, to see if the food contains a
lot or a little of energy or a nutrient in the food
 Step 1: Take note of the reference amount of
food being used in the nutrition label

 Expressed as
per 100 g (or per
100 mL) of food
 Step 1: Take note of the reference amount of
food being used in the nutrition label

 Expressed as per serving (the serving size

(in g or mL) and the no. of servings must
be specified on the package)

47
 Step 1: Take note of the reference amount of
food being used in the nutrition label

 Expressed as per package (if the package contains

only a single serving )
 Self-Care

 Patients should be educated to practice self-care. This

allows the patient to assume responsibility and control
of his / her own diabetes management. Self-care
should include:

◦ Blood glucose monitoring

◦ Body weight monitoring
◦ Foot-care
◦ Personal hygiene
◦ Healthy lifestyle/diet or physical activity
◦ Identify targets for control
◦ Stopping smoking
 Step 2: Read the energy and nutrient content
together with the reference amount

A) Use nutrition label to compare between

products
B) Use nutrition label to calculate the amount of
energy and nutrients you get from food
 Step 2:
Use nutrition label to calculate the amount of energy and
nutrients you get from food

 The more you eat, the more you get

 If you eat 1 serving of biscuit

 Get 8 g of fat, 3.5 g of saturated fat

 If you eat 2 servings of biscuit

 Get 16 g of fat, 7 g of saturated fat

51
Nutrition Labeling is a Useful Tool for Practicing
Healthy Eating

 Nutrition label and nutrition claim can help

consumers choose healthier food in accordance with
healthy eating principles and Food Group Guides, e.g.
 Choose biscuits lower in fat and sodium (or salt)
 Choose dairy products lower in fat
 Choose beverages lower in sugars
 Choosing Prepackaged Foods for People
with Diabetes
 Pay attention to nutrition claims, for example –
 “Sugars free” does not mean that the product does not contain
sugars or carbohydrates (e.g. prepackaged sugars free moon
cake)
 “No added sugars” means that sugars or ingredients that
contain sugars for sweetening purpose are not added during
the food production process. The product may still contain
sugars that are naturally present. (e.g. prepackaged pure fruit
juice)
 “Less sweet” means lower sweet intensity. Sweetness is a taste
which is a subjective experience. Statements on sweetness may
not be directly related to its sugars content. Therefore, a
product with the “less sweet” claim does not necessarily mean
that the product has low or no sugars.
 Choosing Prepackaged Foods for People with
Diabetes
 Nutrition claim only gives a rough idea about the
content of a particular nutrient, one should not make a
food choice solely on the basis of a nutrition claim.
 In order to eat healthily, we should take note of other
nutrients as well.
 For example, when buying a product with a “low sugars”
claim, one should take note of the content of fat and
other nutrients.
 Choosing Prepackaged Foods for People with
Diabetes
Nutrient content claims on sugars are classified into “Free” and “Low”
claims.
Specific Conditions of Nutrient Content Claims –

Claim：
Free; No; Zero; Without; Does
not contain
Meaning of Claim :
Insignificant amount of a
particular nutrient found in the found in the food
food
Example: Sugars free
(Contain not more than 0.5g of
sugars per 100g/mL of food)
Claim：
Low; Little; Low source; Few;
Contains a small amount of
Meaning of Claim :
A small amount of nutrient
Example: Low sugars
(Contain not more than 5g of
sugars per 100g/mL of food)
 References

 Mann, J. (2007). Diabetes mellitus and the metabolic syndrome. In J. Mann & A. S. Truswell
(Eds.), Essentials of human nutrition (3rd Ed.). (pp. 327-342). New York, USA: Oxford
University Press.

 Ramachandarn, A. & Snehalatha, C. (2004). In M., Gibney, M. Elia, O., Ljungqvist, & J.,
Dowsett (Eds.), Public Health Nutrition. (pp. 330-340). Oxford, UK: Blackwell Science Ltd.

 Riccardi, G. Capaldo, B. Rivellese, A. A. (2005). Diabetes mellitus. In C. Geissler & H. Powers

(Eds.), Human Nutrition (3rd Ed.). (pp. 401-414). Edinburgh, UK: Elsevier Churchill
Livingstone.

 Tucker, S. & Dauffenbach, V. (2011). Nutrition and diet therapy for nurses. Boston, USA:
Pearson.

 Valencia, W. M., & Florez, H. (2017). How to prevent the microvascular complications of type 2
diabetes beyond glucose control. Bmj, 356, i6505.

 Zazzo, J. (2006). Nutrition and the pancreas. In M., Gibney, M. Elia, O., Ljungqvist, & J.,
Dowsett (Eds.), Clinical Nutrition. (pp. 193-204). Oxford, UK: Blackwell Science Ltd.
 Review Questions

 Outline the criteria for diagnosis of Diabetes

 Describe the benefits of exercise in diabetes
 Discuss the impact of weight loss in diabetes
management
 Examine the Diabetes Exchange list and identify
pairs of food that can be substituted under each
macronutrient
 Summarize the use of nutrition labelling in diabetes
control
 List one Nutrition claim and explain its assertion