1. Postgraduate Diploma in Diabetes Education
(PDDE
Nutrition therapy: Dietary advice in
case of complications
lec. 3 nutrition therapy that
apply to specific situations
Prepared by;
Dr. Siham M.O. Gritly
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2. Complications of Diabetes
Dr. Siham M.O. Gritly
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3. Dr. Siham M.O. Gritly
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4. Complications of Diabetes
• Complications of Diabetes In both types of
diabetes;
• glucose fails to gain entry into the cells
• and consequently accumulates in the blood.
• These two problems lead to both acute and
chronic complications.
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5. Metabolic Patterns in Diabetes
• Diabetic subjects are constantly relying on protein
and fat for fuel.
• Proteins are degraded for gluconeogenesis.
• Glycolysis is inhibited and gluconeogenesis is
stimulated.
• glucose (and water) are removed in urine. The
diabetic subject suffer from acute hunger and
thirst
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6. • A lack of insulin action leads to mobilization
of fat from adipose tissue, β-oxidation and
formation of ketone bodies.
• In general metabolism shift from carbohydrate
usage to fat usage.
• Excessive buildup of ketone bodies leads to
lowering of the pH.
• When the kidneys can’t keep up with acid-base
homeostasis, ketoacidosis can be fatal
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7. the metabolic changes and acute complications
that can arise in Uncontrolled diabetes.
Adapted from; Ellie Whitney and Sharon Rady Rolfes; Under standing Nutrition, Twelfth Edition. 2011, 2008
Wadsworth, Cengage Learning
• The metabolic consequences of type 1 diabetes differ
from those of type 2.
• Chronically elevated blood glucose alters glucose
metabolism in every cell of the body.
• Some cells begin to convert excess glucose to sugar
alcohols, for example, causing toxicity and cell
distention;
• distended cells in the lenses of the eyes, for
example, cause dim vision.
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8. • Some cells produce glycoproteins by attaching
excess glucose to an amino acid in a protein;
the altered proteins cannot function normally,
• The structures of the blood vessels and nerves
become damaged, leading to loss of circulation
and nerve function.
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9. • Infections occur due to poor circulation
coupled with glucose-rich blood and urine.
• People with diabetes must pay special
attention to hygiene and keep alert for early
signs of infection.
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10. Metabolic Consequences of Untreated
Diabetes Type 1 diabetes
• In type 1, no insulin is available to allow any
glucose to enter the cells.
• When glucose cannot enter the cells, a
metabolic changes quickly follows.
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11. Metabolic Consequences of Untreated Diabetes
Type 1 diabetes
• No glucose enters the cells →
• Cells break down protein and fat which
lead to →
• Ketones produced for energy (ketosis) or
→
• Weight loss that lead to →
• Excessive eating (polyphagia)
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12. •
•
•
•
•
Diabetic ketoacidosis manifested by:
Ketones in the breath (acetone breath)
Ketones in the blood (ketonemia)
Ketones in the urine (ketonuria)
This result in Diabetic coma
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13. Ketone Body Metabolism
• Adipose TG’s provide the major storage form
of readily-available energy
• adipose triglycerids provides FFA’s to liver
which makes ketones that are necessary for
prolonged starvation
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14. • acetoacetate, β-hydroxybutyrate, and acetone
(minor) released into blood since liver cannot
utilize them
• Ketones are used by skeletal, brain and cardiac
muscle, the renal cortex, and other tissues
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15. • When the rate of synthesis of ketone bodies
exceeds the rate of utilization, their
concentration in blood increases;
• acetoacetic acid and beta-hydroxybutyric acid
are acidic, and, if levels of these ketone bodies
are too high, the pH of the blood
drops, resulting in ketoacidosis
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16. • ketonemia. This is followed by ketonuria –
excretion of ketone bodies in urine.
• The ketonemia and ketonuria is commonly
referred as ketosis.
• Smell of acetone in breath is a common feature
in ketosis
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17. Metabolic Consequences of Untreated Diabetes
Type 11 diabetes
• In type 2 diabetes, some glucose enters the
cells.
• In this case the body does not shift into the
metabolism of fasting (losing weight and
producing ketones).
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18. Metabolic Consequences of Untreated Diabetes
Type 11 diabetes
• Some glucose enters the cells, but slowly →
• Hunger →
• Excessive eating (polyphagia) →
• Weight gain
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19. What is Diabetic nephropathy
• Diabetic nephropathy is the impact of diabetes on
the kidneys tissues, lead to loss of protein in the
urine, and eventually chronic kidney
disease requiring dialysis .
• Diabetic nephropathy is a clinical syndrome
characterized by the following:
Persistent albuminuria (>300 mg/d or >200
μg/min) that is confirmed on at least 2
occasions 3-6 months apart
Progressive decline in the glomerular filtration
rate (GFR)
Elevated arterial blood pressure
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20. • Symptoms
• edema: swelling, usually around the eyes in the
mornings;
• later, general body swelling may result, such as
swelling of the legs
• foamy appearance of the urine (caused by the
proteinuria)
• unintentional weight gain (from fluid
accumulation)
• anorexia (poor appetite)
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21. Diabetic nephropathy Kidney failure aggravated by
glomerulosclerosis leads to fluid filtration deficits
and other disorders of kidney function
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22. The earliest detectable change in the course of diabetic
nephropathy is a thickening in the glomerulus. At this
stage, the kidney may leak more serum albumin (plasma
protein) than normal in the urine ( albuminuria),This stage
is called microalbuminuria.
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23. During diabetic nephropathy the kidney becomes damaged and
more protein than normal collects in the urine. As the disease
progresses, more of the kidney is destroyed. Over time, the kidney's
ability to function starts to decline, which may eventually lead to
chronic kidney failure.
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24. Dietary Management of Diabetic
Nephropathy
• Reduce protein to 0.8-1 g/kg/day in individuals
with microalbunimuria.
• Some researchers suggested that In diabetic
nephropathy, protein restriction may vary
between 0.4 – 0.6 g per kilogram
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25. What is diabetic neuropathy?
Diseases of the Nerves
• Neuropathy is damage to nerves, and diabetic
neuropathy is damage to nerves that occurs as a
result of diabetes.
• Diabetic neuropathy is the most common
complication of diabetes.
• Diabetic neuropathy can affect different parts of
the body, and symptoms can range from mild to
severe.
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26. •
•
•
•
Different types of diabetic neuropathy include
Peripheral neuropathy,
focal neuropathy,
Autonomic neuropathy causes symptoms
related to dysfunction of an organ system, such
as urinary incontinence diarrhea, constipation
• and proximal neuropathy. proximal
neuropathy characterized by painful muscle
wasting and weakness.
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27. Peripheral neuropathy most commonly causes
pain, burning, tingling, and numbness of the
feet and lower legs.
diabetic neuropathy together
with vascular disease in the
legs, contributes to the risk of
diabetic-related foot
problems (such as diabetic-food
ulcers) that can be difficult to
treat and occasionally require
amputation
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28. Adapted from; Ellie Whitney and Sharon Rady Rolfes; Under standing
Nutrition, Twelfth Edition. 2011, 2008 Wadsworth, Cengage Learning
Nerve tissues may also deteriorate with
diabetes, expressed at first as a painful
prickling sensation, often in the arms and
legs. Later, the person loses sensation in
the hands and feet.
Injuries to these areas may go
unnoticed, and infections can progress
rapidly. With loss of both circulation and
nerve function, undetected injury and
infection may lead to death of tissue
(gangrene).
gangrene is the death of tissue, usually
due to deficient blood supply,
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29. dietary management of diabetic
neuropathy
• control of blood sugar levels is the best way to
prevent diabetic neuropathy and other
complications of diabetes
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30. Diabetes and Celiac Disease
• Coeliac Disease is a condition where the lining
of the small intestine is damaged due to
sensitivity to a protein in food called gluten.
• Gluten is a protein found in grains such as
wheat, rye, oats, barley. also be found in
processed foods with ingredients such as
wheaten corn flour, wheat starch, malt, malt
extract, malt dextrin and the thickeners
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31. Coeliac Disease and diabetes may occur together
and is more common in people with type 1 than
type 2 diabetes.
Celiac disease
• villous atrophy
• malnutrition
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32. the lining of the small intestine is damaged due
to sensitivity to a protein in food gluten.
Adapted from; Ragnar Hanas, MD, PhD Dept. of
Pediatrics, Uddevalla, Sweden
When the villi are destroyed
by celiac antibodies the
absorption area decrease
A healthy mucosa with villi The
purpose of the villi is to increase
the absorption area of the
intestinal mucosa
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33. The mucosa seen through a microscope
Ref. Ragnar Hanas, MD, PhD
Dept. of Pediatrics, Uddevalla, Sweden
Celiac disease
Normal villi
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34. Onset of celiac disease in first year of life
Symptoms associated
with Celiac Disease
Chronic diarrhoea
Failure to thrive
Abdominal distension
growth failure in children
with diabetes may indicate
the presence of coeliac disease
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35. Symptoms associated with Celiac Disease
• Symptoms vary from person to person and range
from mild to severe
• Malabsorption commonly occurs in people with
undiagnosed coeliac disease and Type 1 DM.
• hypoglycaemia
• Diarrhoea
• Streatorrhoea (floating, fatty stools)
• Loss of weight
• Abdominal bloating or distension
• Flatulence
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36. dietary management of diabetic Celiac
Disease
• A gluten-free diet is currently the only known
treatment for Coeliac Disease.
• Gluten-free foods include corn, rice, sago
, tapioca, buckwheat
, potato, soy, arrowroot, fresh
fruit, vegetables, meat (except most processed
meats), poultry, fish and most dairy foods
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37. • Beans and legumes can be used to increase fiber
content of the diet
• Foods that are low in saturated fat
• Plenty of fruit and vegetables.
• Calcium supplements to be given to reduce risk of
osteoporosis if dietary intake is < 1500 mg/day.
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38. •
•
•
•
•
•
avoid grains such as
wheat,
rye,
oats,
barley.
processed foods with ingredients such as wheaten corn
flour,
• wheat starch,
• malt,
• malt extract,
malt dextrin and the
thickeners
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39. Diabetes and Cystic fibrosis
• Cystic fibrosis a disease that cause damage
to the pancreas (pancreatic insufficiency)
• If enough beta cells are damaged, the body
can’t make enough insulin to metabolize food
• Decreased amounts of insulin lead to raise the
blood glucose levels
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40. • Common symptoms,
• increased thirst
• increased urination, are caused by high blood
sugar levels (hyperglycemia).
• fatigue,
• weight loss
• and unexplained decline in lung function
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41. • Weight loss can occur rapidly because of low
insulin levels and high glucose levels
• high-energy diet with extra calories from fat and
no restriction on carbohydrate is required.
• Keeping blood glucose levels at a normal or nearnormal level
Insulin is primary treatment
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42. Special situations
Inter-current illness
• During acute intercurrent illness, advise on;
• adequate hydration/nutrition especially easily
digested foods/drinks, e.g. soup, yoghurt, jelly, fruit
juice.
• Increase fluids especially if there is
fever, vomiting, or diarrhoea.
• Commercial oral rehydration salts can be used or
even tomato juice or broth.
• Continue medication when ill
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43. • Hospital care
• allow persons with diabetes to make their own
food choices.
• Hospital dieticians should ensure menus have
appropriate or healthy food choices.
• All wards should have food and drink for oral
treatment of hypoglycaemia.
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44. Catabolic illness
• The energy needs of most hospitalised persons can be
met by providing 25-35 kcal/kg body weight.
•
• In catabolic illness, at least 1.0 g/kg body weight up to
1.5 g/kg body weight in more stressed persons.
•
• Avoid overfeeding to prevent
hyperglycaemia, hypertriglyceridaemia and hypertonic
dehydration.
• Correct mineral/vitamin deficiencies before enteral or
parenteral feeding is begun when indicated
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45. Palliative care
• A WHO statement explained palliative care as
"an approach that improves the quality of life
of patients and their families facing the
problems associated with life-threatening
illness, through the prevention and relief of
suffering by means of early identification and
impeccable (perfect) assessment and treatment
of pain and other
problems, physical, psychosocial and
spiritual."
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46. • the term "palliative care" may refer to any care
that alleviates symptoms, whether or not there is
hope of a cure by other means; thus, palliative
treatments may be used to alleviate the side
effects of curative treatments, such as;
• relieving the nausea associated with
chemotherapy
• affirms life and regards dying as a normal
process;
• intends neither to hasten nor to postpone death
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47. • integrates the psychological and spiritual
aspects of patient care;
• offers a support system to help patients live as
actively as possible;
• offers a support system to help the family
cope;
• uses a team approach to address the needs of
patients and their families;
• will enhance quality of life;
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48. • Palliative care is provided by a team of
doctors, nurses, and other specialists who
work together with a patient's other doctors
to provide an extra layer of support. It is
appropriate at any age and at any stage in a
serious illness and can be provided along with
curative treatment.
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49. References
• American Diabetes Association (2002). Clinical Practice
Recommendations:2002. Diabetes Care 25 (suppl. 1):S64-S68.
• Sareen Gropper, Jack Smith and James Groff, Advanced Nutrition and
Human Metabolism, fifth ed. WADSWORTH
• Melvin H Williams 2010; Nutrition for Health, Fitness and Sport. 9th
ed, McGraw Hill
• Heymsfield, SB.; Baumgartner N.; Richard and Sheau-Fang P. 1999.
Modern Nutrition in Health and Disease; Shils E Maurice, Olson A.
James, Shike Moshe and Ross A. Catharine eds. 9th edition
• Guyton, C. Arthur. 1985. Textbook of Medical Physiology. 6th
edition, W.B. Company
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50. • American Diabetes Association. Standards of medical
care in diabetes--2011. Diabetes Care. 2011 Jan;34
Suppl 1:S11-61
• American Diabetes Association. Nutrition
recommendations and interventions for diabetes: a
position statement of the American Diabetes
Association. Diabetes Care. 2008;31:S61-S78.
• American Diabetes Association. Carbohydrate
counting. Available at http://www.diabetes.org/foodand-fitness/food/planning-meals/carbcounting. Accessed December 8, 2012.
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