NUTRICARE IN DIABETES WITH SPECIAL CONDITIONS

PREGNANCY ILLNESS SURGERY GERIATIC POPULATION

NUDRAT KHAN Jr.M.Sc CND

PREGNANCY AND DIABETES 
GESTATIONAL

DIABETES  Diabetes developed during pregnancy DIABETES  Diabetes predates pregnancy 

PRE-GESTATIONAL

GESTATIONAL DIABETES (GDM)
Defined

as ´glucose intolerance of variable severity with onset or first recognition during pregnancyµ. occurs in the latter stage of pregnancy, usually developing around the 24-28 weeks of pregnancy

It

PATHOPHYSIOLOGY
Normal
y

Pregnancy Adaptation

Maternal Metabolic

Diabetogenic state changes in carbohydrate metabolism + physiological Insulin Resistance Hormones of Pregnancy Peripheral Insulin Resistance Insulin needs delivery doubled or tripled by the time of

y

y

y

Pancreas respond by releasing more Insulin to Over come Insulin Resistance

y .B lead to GDM development. Triggered by an Antigenic Load(Fetus) HLA-G is postulated to protect pancreatic islet cells. Interaction between HLA-G and NF.) GDM reduced Insulin response to nutrients Glucose Intolerance y Chronic Insulin resistance Cell Dysfunction y Diabetes + Obesity post-receptor defects are present in the insulin signaling pathway in the placenta.PATHOPHYSIOLOGY (CONT.

Seen in <10 % GDM patients after pregnancy. characterized by circulating anti-islet cell antibodies or -cell antigens such as glutamic acid decarboxylase.PATHOPHYSIOLOGY (CONT. IAA. develop overt diabetes .) Rare cause of GDM autoimmune destruction of pancreatic -cells. or insulin autoantibodies. GAD.

2006) Strong family history of T2D. Glucose intolerance or Pre-diabetes .SCREENING FOR GDM The American Diabetes Association Recommends (ADA. Presence of glycosuria Diagnosis of PCOD (Ross. High Risk criteria are: Severe obesity Maternal age >35 yrs History of GDM or delivery of LGA infant. 2008): 1) Women at high risk should be screened as soon as possible after pregnancy has been confirmed.

.SCREENING FOR GDM (CONT. No history of poor obstetrical outcomes. st No known 1 degree relative with diabetics No history of abnormal glucose tolerance.) 2) Women with high risk who were not found to have diabetes early in pregnancy and those with average risk should be screened at 24-28 weeks of gestation. 3) Women with low risk do not require screeningLow risk criteria Age < 25 years Normal weight before pregnancy. Member of ethnic group with low prevalence of diabetes.

2008 95 mg/dl 180 mg/dl 155 mg/dl 140 mg/dl Two of the above Values must be met or exceeded for a diagnosis of gestational diabetes to be made.DIAGNOSTIC CRITERIA FOR GESTATIONAL DIABETES: 100 g OGTT is performed in the morning after an overnight fast of at least 8 hrs TABLE 1: Diagnostic Criteria for Gestational Diabetes 100 g OGTT Fasting 1-hour 2-hour 3-hour Source: ADA. .

Neonatal Hypoglycemia y Risks associated with this condition are seizures.>4kg or >90th percentile Common complication of vaginal birth like Shoulder dystocia. Other Neonatal Metabolic Problems are Jaundice and calcium or magnesium imbalance. . cerebral damage and rarely death.RISK OF GESTATIONAL DIABETES MATERNAL RISK ARE:- Hypertension Polyhydramnios Caesarian section RISK TO BABY ARE:y Macrosomia.

y GDM in subsequent pregnancies To the Baby are :Obesity & Glucose Intolerance in late adolescence and early Adulthood . y Maintain Normal BMI and Activity of 150 mins/week to prevent development of T2D.RISK IN THE FUTURE To the Mother are:T2D Risk Factor Obesity & Family History y Screened at 6-12 weeks post-partum and every 3 years.

fasting y 140 mg/dl.MANAGEMENT STATEGIES Regular monitoring of Blood glucose at least 4 times a day(fasting & 1 or 2 hour post prandial) & maintaining within target range. The following Target Goals are suggested ADA Recommends 95 mg/dl. This helps in modifying the treatment plan. 1 hour postprandial y 120 mg/dl. All SMBG and urine ketone results should be recorded. 2 hour postprandial y . MNT should be initiated immediately upon diagnosis. SMBG should be initiated immediately after diagnosis is made.

One study found out the a positive correlation between the presence of ketones and low intelligence score in children( Rizzo et al.MANAGEMENT STATEGIES (CONT. y Exercise may induce hypoglycemia if the women is treated with insulin. y Exercise after meals may improve the postprandial blood glucose levels.. EXERCISE Advised to do regular low impact physical activity.) Ketones should be tested if the glucose levels is >200 mg/dl or it the women is sick. y Avoid high impact or strenuous exercise to induce premature labor.1991) Measurement of fetal abdominal circumference early in the third trimester may rule out excess macrosomia risk. Check blood glucose before and after exercise to understand the impact of exercise and action needed to prevent hypoglycemia. y .

There are some studies which show they may be safe to use but because of concerns of teratogenicity and neonatal hypoglycemia it is not generally used.MANAGEMENT STATEGIES (CONT. ORAL GLUCOSE MEDICATION OHA are not routinely used in pregnancy. the women should be started on Insulin. .) INSULIN If it is not possible to maintain blood glucose at target levels for pregnancy within a short time after diagnosis.

(obesity and inc. as the pregnancy progresses.(inc.PRE GESTATIONAL DIABETES OR PREGNANCY IN PREEXISTING DIABETES. in Placental hor.) Women with T2D have IR from the beginning of pregnancy that continues to inc. insulin req. due to morning sickness.) . In women with T1D insulin needs may decrease in early pregnancy when food intake may dec. in placental Hor. After 1st trimester. 2-3 time the prepregnancy amts. will inc. Diabetic women planning pregnancy should ensure they have HbA1c <7%.

PRE-CONCEPTION CARE AND COUNSELLING Its implementation has reduced the perinatal mortality rate & survival rate for both women n infant improved. should began atleast 3-4 months before pregnancy is planned. to achieve better glycemic control before becoming pregnant. It Helps .

Preterm labour Polyhydramnios Pre-eclampsia Eclampsia To the baby: Congenital Malformation(6-10% of the cases) A folic acid supplement of 1-4mg/day from preconception till 13 weeks of Macrosomia Neonatal Hypoglycemia Still Birth .RISK DURING PREGNANCY To the Mother:y y y y y y Progression of preexisting complication Hypoglycemia in 1st trimester.

y RISK IN FUTURE: To Mothery Potential Hypoglycemia if energy intake not inc. during Breast feeding. y To the baby Same as for Gestational Diabetes y Babies are not born with Diabetes.1 in 25 y >25 yrs-1 in 100 y If mother has T2D-1 in 7 If both parents have T2D-1 in 2 . To Baby If mother is T1D <25 yrs.RISK AT DELIVERY To the Mother Caesarian section y Effects of Pre-eclampsia or eclampsia.

0. if possible) .0(”6. if possible) 60-90mg/dl <120 mg/dl (”6.MONITORING y SBGM and Ketone Testing should be done regularly Recommended Glycemic Targets Glycemic Target y Prepregnancy HbA1c(%) Once Pregnant FBG 1-hour PPG HbA1c(%) Source ADA 2004 ” 7.0.

SURGERY AND DIABETES PERIOPERATIVE DIABETES CARE HYPERGLYCEMIA has been identified as a risk factor for perioperative morbidity and mortality .

Pathophysiology of hyperglycemia in Critically Ill patients undergoing Surgery ‡Hemodynamic Instability ‡Tachycardia ‡Electrolyte Imbalance ‡Inc. levels of inflammatory mediators ‡Endothelial cell dysfunction ‡Defects in immune function ‡Increased oxidative stress ‡Prothrombotic changes ‡cardiovascular effects ‡Inc. susceptibility to infection ‡Organ dysfunction .

A.18:426-435 . K. A.J Am Acad Orthop Surg. Chillag.Surgical Risks and the Benefits of Improved Glucose Control Source: Rizvi.J(2010) Perioperative Management of Diabetes and Hyperglycemia in Patients Undergoing Orthopaedic Surgery. Chillag. Surgery.

in intensive glucose control as compared with conventional control . of death at 90 days.104 patients in the intensive care unit. Increased no. Undiagnosed diabetes and hospital-induced hyperglycemia contribute to increased postoperative complications. Intravenous (IV) insulin was used to achieve a blood glucose level of 81 to 108 mg/dL in the intensive group and 144 to 180 mg/dL in the conventional group. (NICE-SUGAR) trial in which Intensive and conventional glycemic control were compared in 6. patients with diabetes undergo more surgical procedures than do patients without diabetes. They are at even greater risk than those with preexisting diabetes. & should be treated in a similar fashion Because of associated musculoskeletal complications.

maintain the glucose level between 140 and 180 mg/dL. A consensus statement of the American Association of Clinical Endocrinologists and the American Diabetes Association has since recommended (2009) revising glucose targets as follows: In critically ill patients. Targets<110 mg/dL are not recommended. . Greater benefit may be realized at the lower end of this range.

average postprandial plasma glucose <180 mg/dL It may be advisable to delay surgery a few weeks to a few months to obtain satisfactory glucose control.PREOPERATIVE MANAGEMENT Glycemic targets as close as possible to those advocated by the American Diabetes Association should be achieved before a planned surgical procedure. These targets include HbA1C <7.0%. . average preprandial plasma glucose : 90 -130 mg/dL.

Insulin errors and omissions are common. malnutrition. sepsis. and CHF. Use of oral sulfonylurea agents in elderly patients who are prone to hepatorenal insufficiency.INPATIENT HYPOGLYCEMIA Factors predisposingto hypoglycemia include advanced age hypoglycemia unawareness or an altered ability to report hypoglycemic symptoms.polypharmacy. Insulin is one of the major a high-risk medications in the inpatient setting . renal insufficiency or dialysis. or drug interactions may be contributory factors. liver disease.

ILLNESS AND DIABETES SICK DAY MANAGEMENT .

SICK DAY MANAGEMENT Diabetics should be aware that common illnesses such as cold. Illness stress release of counterregulatory hormones to fight infection & liver glycogen is released. diarrhoea. flu-like symptoms like vomiting. Without . sore throat and infection may rise blood glucose levels. extra insulin blood glucose will rise DKA or HHS will dev. If enough insulin is not available.

vomiting and diarrhoea people should drink 250ml of sugar free. . caffeine-free fluids evry hour. 4. Following these rules may help people with diabetes prevent the development of DKA or HHS. report high levels to Dr. immediately. immediately. Never skip an injection or medication Check urine for ketones y y If bld Glu >240mg/dl Presence of ketones should be reported to Dr. Check Blood Glucose y Every 2-4 hrs. 2. Every 3 hours soups that contains sodium. 3. Drink fluids y To replace fluids lost through High Blood glucose.SICK DAY RULES 1. fever.

GERIATRIC POPULATION AND DIABETES .

Reduction in levels of gastric and intestinal enzymes poor digestion and absorption of food.EFFECT OF AGING ON GLYCEMIC CONTROL Geriatric patients face various medical and environmental problems which make it difficult for them to achieve good glycemic control. PHYSIOLOGICAL CHANGES Reduced food Intake decreased appetite. . lack of saliva. lack of teeth and gum diseases . reduced taste buds. Malabsorption complicate the dietary and pharmalogical management of diabetes and predispose to malnutrition.Reduced physical activity and basal metabolic rate.

.g. Orlistat G. DEHYDRATION Altered thirst perception and delayed fluid supplementation Dehydration hyperosmolar coma .POLYPHARMACY Chronic y y drug administration Drug Interaction Nutritional deficiency e. metformin causes folate and vitamin B12 deficiency.I side effect Malabsorption.

spinal disease and muscular disease reduction in mobility. Ocular complications reduced Visual acuity reduces the effectiveness of visual cues associated with appetite and hunger. osteoporosis. morbid conditions such as arthritis.FUNCTIONAL IMPAIRMENT Cognitive dysfunction + loss of memory associated decrease in compliance with drug therapy. increase in fall and Injury. Co .

The renal threshold for glucose increases with advanced age. Islet cell antibodies and marked insulin deficiency are increasingly seen in lean elderly diabetic patients. Obese elderly patients Insulin resistance. Glucose counter regulatory hormones responses to hypoglycemia are diminished reduction in autonomic warning symptoms. and glucosuria is not seen at usual levels . Hypoglycemia is often a risk of diabetes treatment in the elderly. Lean elderly patients Impaired glucose-induced insulin release.ALTERATIONS IN CARBOHYDRATE METABOLISM Loss of first-phase insulin release.

Therapy should be chosen based on the individual needs and issues of each patient.MANAGEMENT Goals of therapy for elderly diabetic patients should include an evaluation of their functional status. Restricting caloric intake in longterm care patients should be done with much caution. and their own desires for treatment. providers should pay special attention to possible side effects and drug interactions . life expectancy. and diminished appetite. Many already have insufficient caloric intake because of confusion. social and financial support. dysphagia. particular attention should be given to functional goals and to avoiding therapies that may cause loss of independence or early institutionalization. When prescribing insulin or oral agent regimens for this population. In frail elderly patients.

especially for those older adults with reduced energy intake .Glucose monitoring equipment should be easy to handle. weakness. hypoglycemia may manifest itself solely in terms of neuroglycopenic symptoms (dizziness. A daily multivitamin supplement may be appropriate. Make sure that the patient understands how to identify hypoglycemia. In the elderly. confusion. increased adherence to plan & better outcome. Instruction should be given at slow pace along with hand outs(memory aid). delirium) Taking into consideration personal preference.

musculoskeletal injuries.EXERCISE Physical activity attenuate loss of lean body mass. decrease central adiposity. diabetic patient should undergo a thorough medical evaluation before increasing physical activity. Exercise Elderly . and hypoglycemia in patients treated with insulin or insulin secretagogues. also poses potential risks such as cardiac ischemia. and improve insulin sensitivity.

Appropriate foot wear. changes in autonomic nervous system function. .FOOT CARE Alterations in blood flow to the microvascular structures of the feet. applications of lipid-based lotions to dry feet and early intervention when feet lesions occur are all key factors in the prevention of amputations. Careful attention to the feet is of paramount importance in older people with diabetes. are the major causative factors in the pathogenesis of foot ulcers infection and amputation Elevated Glucose level leaching of zinc in urine zinc deficiency Poor wound healing.

Use of premixed insulins or prefilled insulin pens as an alternative to mixing insulins should be considered. Should be used with caution in elderly patients with cardiovascular disease. but hypoglycemia remains the main adverse effect of concern. Thiazolinediones are effective but associated with an increased incidence of edema and CHF in the elderly. but tolerance of these agents is a problem. Sulfonylreas are effective agents in the elderly. Dosage errors may result with loss of concentration and memory.PHARMACOLOGICAL CONSIDERATION For lean elderly patients with T2D. agents that promote insulin secretion should be selected. Insulin therapy poses special concerns. . Alpha-glucosidase inhibitors are modestly effective for glycemic control. while in obese elderly patients agents that lower insulin resistance should be selected. failing eyesight and manual dexterity.

V. (2009)Perioperative Glycemic Control.18:426-435 .BIBLIOGRAPHY India Diabetes Educator Project(2008) Distance Learning Manual...C. Volume 19.D and Edelman S.C.J Am Acad Orthop Surg. Number 4 Angela K. Clinical Diabetes. Chau. and Michael A. Shawn A. G. M.R.(2001) Clinical Management of diabetes in Elderly. Anesthesiology 110:408²21 Ali A.Kim J.(2010)Perioperative Management of Diabetes and Hyperglycemia in Patients Undergoing Orthopaedic Surgery.

Master your semester with Scribd & The New York Times

Special offer for students: Only $4.99/month.

Master your semester with Scribd & The New York Times

Cancel anytime.