13.1 Diabetes Mellitus

Diabetes mellitus is a complex metabolic disorder affecting millions worldwide. This section dives into its types, complications, and nutritional risk factors, emphasizing the crucial role of diet and lifestyle in managing the condition.

Understanding diabetes is key to effective nutrition assessment in chronic diseases. We'll explore how dietary choices, physical activity, and body composition impact diabetes risk and management, as well as strategies for creating personalized nutrition care plans.

Diabetes Mellitus Pathophysiology

Types and Characteristics of Diabetes

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• Diabetes mellitus is a group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both
• Type 1 diabetes is an autoimmune disorder that leads to the destruction of pancreatic beta cells, resulting in absolute insulin deficiency
  • Typically presents in childhood or adolescence
  • Requires lifelong insulin replacement therapy to manage blood glucose levels
• Type 2 diabetes is characterized by insulin resistance and relative insulin deficiency
  • Often associated with obesity and typically presents in adulthood
  • Can be managed through lifestyle modifications, oral medications, and sometimes insulin therapy
• Gestational diabetes occurs during pregnancy due to hormonal changes that lead to insulin resistance
  • Usually resolves after delivery but increases the risk of developing type 2 diabetes later in life
  • Requires close monitoring of blood glucose levels and may necessitate dietary modifications and insulin therapy during pregnancy

Complications of Chronic Hyperglycemia

• Chronic hyperglycemia in diabetes can lead to long-term complications, such as retinopathy, nephropathy, neuropathy, and cardiovascular disease
• Retinopathy involves damage to the blood vessels in the retina, potentially leading to vision loss or blindness
• Nephropathy is characterized by damage to the kidneys, which can progress to end-stage renal disease requiring dialysis or transplantation
• Neuropathy affects the nerves, causing sensory loss, pain, and autonomic dysfunction (gastroparesis, orthostatic hypotension)
• Cardiovascular disease, including coronary artery disease, stroke, and peripheral artery disease, is a major cause of morbidity and mortality in individuals with diabetes

Nutritional Risk Factors for Diabetes

Dietary Factors

• High intake of saturated and trans fats can worsen insulin resistance and increase the risk of diabetes complications
  • Saturated fats are found in animal products (fatty meats, full-fat dairy) and some tropical oils (coconut oil, palm oil)
  • Trans fats are found in partially hydrogenated oils, fried foods, and some processed snacks and baked goods
• Excessive consumption of added sugars, particularly from sugar-sweetened beverages, can contribute to weight gain and increase the risk of type 2 diabetes
  • Added sugars are found in soft drinks, fruit juices, sweetened teas and coffees, and many processed foods (cookies, cakes, candies)
  • The American Heart Association recommends limiting added sugars to no more than 36 grams per day for men and 25 grams per day for women
• Low intake of dietary fiber, especially from whole grains, fruits, and vegetables, is associated with a higher risk of diabetes
  • Fiber helps slow glucose absorption, improves insulin sensitivity, and promotes feelings of fullness
  • Good sources of fiber include whole grains (oats, quinoa, brown rice), fruits (berries, apples, pears), vegetables (broccoli, carrots, spinach), and legumes (beans, lentils, peas)
• Inadequate intake of micronutrients, such as vitamin D, magnesium, and chromium, may play a role in the development and management of diabetes
  • Vitamin D deficiency has been linked to impaired insulin secretion and insulin resistance
  • Magnesium is involved in glucose metabolism, and low levels may worsen insulin resistance
  • Chromium enhances the action of insulin and may improve glucose tolerance

Lifestyle Factors

• Obesity, particularly central obesity, is a significant risk factor for the development of type 2 diabetes
  • Excess body fat, especially around the waist, contributes to insulin resistance
  • Losing 5-10% of body weight can significantly improve insulin sensitivity and reduce the risk of developing type 2 diabetes
• Sedentary lifestyle and physical inactivity can exacerbate insulin resistance and increase the risk of type 2 diabetes
  • Regular physical activity (150 minutes per week of moderate-intensity exercise) helps improve insulin sensitivity, glycemic control, and body composition
  • Engaging in both aerobic exercise (brisk walking, cycling, swimming) and resistance training (weightlifting, bodyweight exercises) is beneficial for individuals with or at risk of diabetes

Nutritional Status in Diabetes

Anthropometric Measurements

• Assess anthropometric measurements, such as body mass index (BMI), waist circumference, and body composition, to determine the presence of overweight or obesity
  • BMI is calculated as weight (kg) divided by height (m) squared; a BMI of 25-29.9 indicates overweight, while a BMI of 30 or above indicates obesity
  • Waist circumference measures central adiposity; a waist circumference greater than 40 inches for men or 35 inches for women indicates increased risk of metabolic disorders
  • Body composition analysis (skinfold measurements, bioelectrical impedance) can provide information on the proportion of fat mass to lean mass

Dietary Assessment

• Review dietary intake through methods such as 24-hour recall, food frequency questionnaires, or food diaries to identify potential nutritional imbalances or excesses
  • 24-hour recall involves asking the individual to recount all foods and beverages consumed in the previous 24 hours
  • Food frequency questionnaires assess the usual intake of specific foods or food groups over a given period (e.g., the past month or year)
  • Food diaries require the individual to record all foods and beverages consumed, along with portions sizes, over a set period (usually 3-7 days)
• Analyze macronutrient distribution, focusing on carbohydrate quality and quantity, fat types, and protein adequacy
  • Assess the proportion of total energy intake from carbohydrates, fats, and proteins
  • Evaluate the quality of carbohydrates consumed, emphasizing whole grains, fruits, vegetables, and legumes over refined carbohydrates and added sugars
  • Examine the types of fats consumed, encouraging the replacement of saturated and trans fats with monounsaturated and polyunsaturated fats (olive oil, nuts, seeds, fatty fish)
  • Ensure adequate protein intake (0.8-1.0 g/kg body weight) to maintain lean body mass and support overall health
• Evaluate micronutrient intake and status, particularly for nutrients that may be deficient in individuals with diabetes, such as vitamin D, magnesium, and chromium
  • Assess dietary sources of these nutrients and consider the need for supplementation based on individual needs and laboratory values
  • Monitor vitamin B12 status in individuals taking metformin, as this medication may reduce B12 absorption

Glycemic Control and Complications

• Assess glycemic control through measures like fasting blood glucose, postprandial blood glucose, and hemoglobin A1c (HbA1c) to determine the effectiveness of current nutrition and medical management
  • Fasting blood glucose measures blood sugar levels after an 8-12 hour fast; a value of 126 mg/dL or higher on two separate occasions indicates diabetes
  • Postprandial blood glucose measures blood sugar levels 2 hours after a meal; a value of 200 mg/dL or higher indicates diabetes
  • HbA1c reflects average blood glucose levels over the past 2-3 months; an HbA1c of 6.5% or higher indicates diabetes, while a value of 5.7-6.4% indicates prediabetes
• Consider the presence of diabetes complications, such as nephropathy or gastroparesis, which may require specific nutritional modifications
  • Nephropathy may necessitate protein and potassium restrictions to slow the progression of kidney disease
  • Gastroparesis may require smaller, more frequent meals and the avoidance of high-fat and high-fiber foods to manage symptoms of delayed gastric emptying

Nutrition Care Plans for Diabetes

Individualized Goals and Macronutrient Distribution

• Set individualized glycemic, blood pressure, and lipid goals based on the patient's age, duration of diabetes, comorbidities, and personal preferences
  • Glycemic targets may be more stringent for younger individuals with a shorter duration of diabetes and less strict for older individuals or those with advanced complications
  • Blood pressure goals are typically <140/90 mmHg, but may be lower (<130/80 mmHg) for individuals with high cardiovascular risk
  • Lipid goals focus on lowering LDL cholesterol, raising HDL cholesterol, and reducing triglycerides to minimize cardiovascular risk
• Determine energy requirements and macronutrient distribution to achieve and maintain a healthy body weight and optimize glycemic control
  • Adjust energy intake based on the individual's current weight status, weight loss goals, and physical activity level
  • Distribute macronutrients as follows: 45-65% of total energy from carbohydrates, 20-35% from fats (<10% from saturated fats), and 15-20% from proteins
  • Emphasize the importance of carbohydrate quality, focusing on whole grains, fruits, vegetables, and legumes, while limiting added sugars and refined carbohydrates
  • Encourage the consumption of healthy fats, such as monounsaturated and polyunsaturated fats, while reducing saturated and trans fats
  • Ensure adequate protein intake to maintain lean body mass and support overall health

Meal Planning and Education

• Develop meal planning strategies, such as carbohydrate counting, the plate method, or the exchange system, to help individuals manage their food intake and blood glucose levels
  • Carbohydrate counting involves tracking the grams of carbohydrates consumed at each meal and snack to maintain consistent carbohydrate intake
  • The plate method involves filling half the plate with non-starchy vegetables, one-quarter with lean proteins, and one-quarter with carbohydrates (whole grains, starchy vegetables, or fruits)
  • The exchange system categorizes foods into groups based on their macronutrient content, allowing for flexibility in meal planning while maintaining consistent nutrient intake
• Incorporate regular physical activity into the nutrition care plan to improve insulin sensitivity, glycemic control, and overall health
  • Encourage a combination of aerobic exercise (150 minutes per week of moderate-intensity activity) and resistance training (2-3 sessions per week)
  • Provide guidance on adjusting carbohydrate intake and insulin dosages based on the timing, duration, and intensity of physical activity
• Address any identified micronutrient deficiencies or excesses through dietary modifications or supplementation as needed
  • Recommend food sources rich in vitamins and minerals of concern (e.g., fatty fish, egg yolks, and fortified dairy for vitamin D; nuts, seeds, and whole grains for magnesium; lean meats, nuts, and whole grains for chromium)
  • Consider supplementation when dietary intake is insufficient or when deficiencies are confirmed through laboratory testing
• Provide education on the importance of self-monitoring of blood glucose, proper medication use, and the recognition and treatment of hypoglycemia and hyperglycemia
  • Teach individuals how to use a blood glucose meter, interpret results, and adjust their nutrition and medication plans accordingly
  • Review the signs, symptoms, and treatment of hypoglycemia (confusion, sweating, shakiness, headache) and hyperglycemia (frequent urination, increased thirst, blurred vision)
  • Emphasize the importance of adhering to prescribed medications, including insulin and oral glucose-lowering agents, and understanding their potential side effects

Monitoring and Adjustments

• Regularly monitor and adjust the nutrition care plan based on changes in the individual's nutritional status, glycemic control, and overall health goals
  • Reassess anthropometric measurements, dietary intake, and glycemic control at regular intervals (e.g., every 3-6 months) to evaluate progress and identify areas for improvement
  • Modify energy intake, macronutrient distribution, and meal planning strategies as needed to optimize weight management and glycemic control
  • Adjust physical activity recommendations based on the individual's progress, preferences, and any physical limitations or comorbidities
  • Collaborate with the individual's healthcare team (primary care physician, endocrinologist, pharmacist) to ensure a coordinated approach to diabetes management
  • Provide ongoing education and support to help individuals maintain lifestyle changes and adapt to new challenges in their diabetes management journey