Pacaña, Christy Rei T.

2BSN-B8

Nutrition and Diet Therapy – Lecture

STUDENT ACTIVITY SHEET BS NURSING / SECOND YEAR
Session # 20

LESSON TITLE: Carbohydrate Controlled Diets for Materials:

Diabetes Mellitus Pen and notebook

LEARNING OUTCOMES:

At the end of the lesson, you can:

1. Characterize type 1 and type 2 diabetes; Reference:
2. Describe the complications associated with these DeBruyne, L.K., Pinna, K., & Whitney E., (2016).
conditions; Nutrition and diet therapy: Principles and practice
3. Describe how diabetes is managed using individualized (9th ed.). USA: Cengage Learning.
dietary adjustments, medications, and physical activity
plans; and,
4. Explain how diabetes can affect pregnancy outcomes and
describe the approaches used to maintain glycemic
control in pregnant women with diabetes.

LESSON PREVIEW/REVIEW Instruction:

Let us have a review of what you have learned from the previous lesson. Kindly answer the following questions on the
space provided. You may use the back page of this sheet, if necessary. Have fun!

Instruction: In 4-5 sentences explain the nutrition therapy for patients with liver cirrhosis.
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MAIN LESSON
You will study and read their book, if available, about this lesson.

A. Overview of Diabetes Mellitus

The term diabetes mellitus refers to metabolic disorders characterized by elevated blood glucose concentrations and
disordered insulin metabolism. People with diabetes may be unable to produce sufficient insulin or to use insulin
effectively, or they may have both types of abnormalities. These impairments result in defective glucose uptake and
utilization in muscle and adipose cells and unrestrained glucose production in the liver. The result is hyperglycemia, a
marked elevation in blood glucose levels that can ultimately cause damage to blood vessels, nerves, and tissues.

Symptoms of Diabetes Mellitus

⎯ Frequent urination (polyuria)
⎯ Dehydration, dry mouth
⎯ Excessive thirst (polydipsia)
⎯ Weight loss
⎯ Excessive hunger (polyphagia)
⎯ Blurred vision
⎯ Increased infections
⎯ Fatigue

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Diagnosis of Diabetes.

The diagnosis of diabetes is based primarily on plasma glucose levels, which can be measured under fasting conditions or
at random times during the day. In some cases, an oral glucose tolerance test is given: the individual ingests a 75-gram
glucose load, and plasma glucose is measured at one or more time intervals following glucose ingestion. Glycated
hemoglobin (HbA1c) levels, which reflect hemoglobin’s exposure to glucose over the preceding 2 to 3 months, are an
indirect assessment of blood glucose levels. The following criteria are currently used to diagnose diabetes:
⎯ The plasma glucose concentration is 126 mg/dL or higher after a fast of at least eight hours (normal fasting
plasma glucose levels are 75 to 100 mg/dL).
⎯ In a person with classic symptoms of diabetes, the plasma glucose concentration of a random, or casual, blood
sample (obtained from a non-fasting individual) is 200 mg/dL or higher.
⎯ The plasma glucose concentration measured two hours after a 75-gram glucose load is 200 mg/dL or higher.
⎯ The HbA1c level is 6.5 percent or higher.

B. Types of Diabetes

Type 1 Diabetes. Type 1 diabetes accounts for about 5 to 10 percent of diabetes cases. It is usually caused by
autoimmune destruction of the pancreatic beta cells, which produce and secrete insulin. By the time symptoms develop,
the damage to the beta cells has progressed so far that insulin must be provided, most often by injection. Although the
reason for the autoimmune attack is usually unknown, environmental toxins or infections are likely triggers. People with
type 1 diabetes often have a genetic susceptibility for the disorder and are at increased risk of developing other
autoimmune diseases

Type 1 diabetes usually develops during childhood or adolescence, and symptoms may appear abruptly in previously
healthy children. Classic symptoms are polyuria, polydipsia, weight loss, and weakness or fatigue.

Ketoacidosis—acidosis due to the excessive production of ketone bodies—is sometimes the first sign of disease.
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
development of the disease in close relatives.

Type 2 Diabetes. Type 2 diabetes is the most prevalent form of diabetes, accounting for 90 to 95 percent of cases. The
defect in type 2 diabetes is insulin resistance, the reduced sensitivity to insulin in muscle, adipose, and liver cells, coupled
with relative insulin deficiency, the lack of sufficient insulin to manage glucose effectively.

Normally, the pancreatic beta cells secrete more insulin to compensate for insulin resistance. In type 2 diabetes, insulin
levels are often abnormally high (hyperinsulinemia) but the additional insulin is insufficient to compensate for its
diminished effect in cells. Thus, the hyperglycemia that develops represents a mismatch between the amount of insulin
required and the amount produced by beta cells. Beta cell function tends to worsen over time in people with type 2
diabetes, and insulin production declines as the condition progresses.

Although the precise causes of type 2 diabetes are unknown, risk is substantially increased by obesity (especially
abdominal obesity), aging, and physical inactivity. The majority of individuals with type 2 diabetes are obese, and obesity
itself can directly cause some degree of insulin resistance. Prevalence increases with age and probably exceeds 25
percent in persons older than 65 years; however, many cases remain undiagnosed.

Type 2 Diabetes in Children and Adolescents. Although most cases of type 2 diabetes are diagnosed in individuals who
are over 40 years of age, 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 diabetes are sometimes
difficult to distinguish in children, however, and a few studies suggest that some children diagnosed with type 1 diabetes
may actually have had type 2 diabetes.

Acute Complications of Diabetes Mellitus. Untreated 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, hypoglycemia is a possible complication of inappropriate disease
management.

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Diabetic Ketoacidosis in Type 1 Diabetes A severe lack of insulin causes diabetic ketoacidosis. 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, fueling the
production of ketone bodies and glucose. Ketone bodies, which are acidic, can reach dangerously high levels in the blood
(ketoacidosis) and spill into the urine (ketonuria). 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 1,000 mg/dL in severe cases.

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The main features of diabetic ketoacidosis therefore include severe ketosis, acidosis, and hyperglycemia. Patients with
ketoacidosis may exhibit symptoms of both acidosis and dehydration. Acidosis is partially corrected by exhalation of
carbon dioxide, so rapid or deep breathing is characteristic. Ketone accumulation is sometimes evident by a fruity odor on
a person’s breath (acetone breath). Significant urine loss (polyuria) accompanies the hyperglycemia, lowering blood
volume and blood pressure and depleting electrolytes.

In response, patients may demonstrate marked fatigue, lethargy, nausea, and vomiting. Mental state may vary from alert
to comatose (diabetic coma). 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.

Hyperosmolar Hyperglycemic Syndrome in Type 2 Diabetes The hyperosmolar hyperglycemic syndrome is a condition
of severe hyperglycemia and dehydration that develops in the absence of significant ketosis. The condition often evolves
slowly, over one week or longer. It is usually precipitated by a serious illness or infection that worsens hyperglycemia and
results in substantial fluid losses due to polyuria or diarrhea; in addition, the patient is unable to recognize thirst or replace
fluids adequately due to age, illness, sedation, or incapacity. The profound dehydration that eventually develops
exacerbates 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 neurological abnormalities, confusion, speech or vision impairments,
muscle weakness, abnormal reflexes, and seizures; about 10 percent of patients lapse into coma. Treatment includes
intravenous fluid and electrolyte replacement and insulin therapy.

Hypoglycemia. Hypoglycemia, or low blood glucose, is due to the inappropriate management of diabetes rather than the
disease itself. It is usually caused by excessive doses 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 3 to 4 percent of deaths in this population.

Symptoms of hypoglycemia include sweating, heart palpitations, shakiness, hunger, weakness, dizziness, and irritability.
Mental confusion may prevent a person from recognizing the problem and taking such corrective action as ingesting
glucose tablets, juice, or candy.

C. Chronic Complications of Diabetes

Prolonged hyperglycemia can damage cells and tissues. Glucose non-enzymatically combines with proteins, producing
molecules that eventually break down to form reactive compounds known as advanced glycation end products (AGEs);
in diabetes, these AGEs accumulate to such high levels that they alter the structures of proteins and stimulate metabolic
pathways that are damaging to tissues. Chronic complications of diabetes typically involve the large blood vessels
(macrovascular complications), smaller vessels such as arterioles and capillaries (microvascular complications), and
the nerves (diabetic neuropathy). Complications may appear 15 to 20 years after diabetes onset.
⎯ Macrovascular Complications. The damage caused by diabetes accelerates the development of atherosclerosis
in the arteries of the heart, brain, and limbs. Cardiovascular diseases are the leading cause of death in people
with diabetes, accounting for up to 70 percent of deaths. Peripheral vascular disease (impaired blood circulation
in the limbs) increases the risk of claudication (pain while walking) and contributes to the development of foot
ulcers. Left untreated, foot ulcers can lead to gangrene (tissue death), and some patients require foot
amputation, a major cause of disability in diabetes.
⎯ Microvascular Complications. Long-term diabetes causes progressive damage to capillaries in the retina
(diabetic retinopathy), leading to visual impairments and, in some cases, blindness. Damage to the kidneys’
specialized capillaries (diabetic nephropathy) prevents adequate blood filtration, and kidney failure often
develops, requiring the use of dialysis (artificial filtration of blood) for survival. Retinopathy and nephropathy
progress most rapidly when diabetes is poorly controlled, and intensive diabetes management can help slow the
progression of these conditions.
⎯ Diabetic Neuropathy. Symptoms of diabetic neuropathy vary and may be experienced as deep pain or burning in
the legs and feet, weakness of the arms and legs, or numbness and tingling in the hands and feet. Pain and
cramping, especially in the legs, are often severe during the night and may interrupt sleep. Neuropathy also
contributes to the development of foot ulcers because cuts and bruises may go unnoticed until wounds are
severe. Other manifestations of neuropathy include sweating abnormalities, disturbances in bladder and bowel
function, sexual dysfunction, constipation, and delayed stomach emptying (gastroparesis

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D. 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 glycemic 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
antidiabetic medications or insulin. 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.

The main goal of diabetes treatment is to maintain blood glucose levels within a desirable range to prevent or reduce the
risk of complications.

Evaluating Diabetes Treatment

Goals for glycemic control in adults (non-pregnant):

⎯ Before meals: 70–130 mg/dL
⎯ One to two hours after the start of a meal
⎯ HbA1c: <7.0%

Comparison of HbA1c and plasma glucose levels:

HbA1c (%) Average glucose levels (mg/dL)
6 126
7 154
8 183
9 212

Nutrition Therapy: Dietary Recommendations

Macronutrient DRI for adults

Macronutrient ranges (% of total kcal):
⎯ Carbohydrate: 45–65%
⎯ Fat: 20–35%
⎯ Protein: 10–35%
⎯ Carbohydrate RDA: 130 g/day
⎯ Fiber AI: 21–38 g/day
⎯ Protein RDA: 0.8 g/kg body weight

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Nutrition Therapy: Meal-Planning Strategies

Carbohydrate Counting. Carbohydrate-counting techniques are simpler and more flexible than other menu-planning
approaches and are widely used for planning diabetes diets.

Carbohydrate counting is taught at different levels of complexity depending on a person’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 counting allows
more flexibility but is best suited for patients using intensive insulin therapy. With this method, a person can determine the
specific dosage of insulin needed to cover the amount of carbohydrate consumed in a meal

Food Lists for Diabetes. A meal-planning system 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.

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

Insulin Preparations. 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.

Insulin Delivery. Insulin is most often administered by subcutaneous 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
syringes, which are filled from vials that contain multiple doses of insulin, are the most common devices used for injecting
insulin.

Another option is to use insulin pens, injection devices that resemble permanent marking pens. Disposable insulin pens
are prefilled with insulin and used one time only, whereas reusable pens can be fitted with prefilled insulin cartridges and
replaceable needles.

Insulin Therapy and Hypoglycemia. Hypoglycemia 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 intensive 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 with the immediate intake of glucose or a
glucose containing food. Usually, 15 to 20 grams of carbohydrate can relieve hypoglycemia in about 15 minutes, although
patients should monitor their blood glucose levels in case additional treatment is necessary.

Each of the following sources provides about 15 g of carbohydrate:

⎯ Glucose tablets: 4 tablets
⎯ Table sugar: 4 tsp
⎯ Honey: 1 tbs
⎯ Jelly beans: 15 small

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 ⎯ Orange juice: ½ c
Diet- Drug Interactions

Insulin therapy is required for patients who are unable to produce sufficient insulin and may be used in both type 1 and
type 2 diabetes. Antidiabetic drugs prescribed for type 2 diabetes improve hyperglycemia by various modes of action.

Physical activity can improve glycemic control and enhance various aspects of general health. Illness can worsen
glycemic control and often requires medication adjustments.

Diabetes and Pregnancy

Careful management of blood glucose levels before and during pregnancy may prevent complications in mother and
infant. 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 glucose
levels; insulin or an antidiabetic drug may be prescribed to help them maintain glycemic control.

CHECK FOR UNDERSTANDING

You will answer and rationalize this by yourself. This will be recorded as your quiz. One (1) point will be given to the
correct answer and another one (1) point for the correct ratio. Superimpositions or erasures in your answer/ratio is not
allowed.

1. Which of the following is characteristic of type 1 diabetes?

a. Abdominal obesity increases risk.
b. The pancreas makes little or no insulin.
c. It is the predominant form of diabetes.
d. It often arises during pregnancy.
ANSWER: ________ b.
RATIO:___________________________________________________________________________________________
Type 1 diabetes is characterized by absolute insulin deficiency, usually resulting from the autoimmune
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destruction of pancreatic beta cells.
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2. Which of the following is true about type 2 diabetes?

a. It is usually an autoimmune disease.
b. The pancreas makes little or no insulin.
c. Diabetic ketoacidosis is a common complication.
d. Chronic complications may develop before it is diagnosed.
ANSWER: ________ d.

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RATIO:___________________________________________________________________________________________
In type 2 diabetes, chronic complications may develop before it is diagnosed.
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3. Most chronic complications associated with diabetes result from:

a. altered kidney function.
b. infections that deplete nutrient reserves.
c. weight gain and hypertension.
d. damage to blood vessels and nerves.
ANSWER: ________ d.
RATIO:___________________________________________________________________________________________
Chronic complications of diabetes typically involve the large blood vessels (macrovascular complications),
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smaller vessels such as arterioles and capillaries (microvascular complications), and the nerves (diabetic neuropathy).
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4. The most effective meal-planning strategy for managing diabetes is:

a. carbohydrate counting.
b. an eating plan based on food lists created for persons with diabetes.
c. following menus and recipes provided by a registered dietitian.
d. the approach that best helps the patient control blood glucose levels.
ANSWER: ________d.
RATIO:___________________________________________________________________________________________
The most effective meal-planning strategy for managing diabetes is the approach that best helps the patient
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control blood glucose levels.
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5. Which dietary adjustment may be helpful for women with gestational diabetes?
a. Consuming most of the day’s carbohydrate allotment in the morning
b. Restricting carbohydrate to about 30 grams at breakfast
c. Avoiding food intake after dinner
d. Reducing energy intake to about 50 percent of the calculated requirement
ANSWER: ________b.
RATIO:___________________________________________________________________________________________
For women with gestational diabetes, carbohydrate is usually poorly tolerated in the morning; therefore,
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restricting carbohydrate (to about 30 grams) at breakfast may be helpful.
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RATIONALIZATION ACTIVITY
The instructor will now provide you the rationalization to these questions. You can now ask questions and debate among
yourselves. Write the correct answer and correct/additional ratio in the space provided.
1. ANSWER: ________
RATIO:________________________________________________________________________________________
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2. ANSWER: ________
RATIO:________________________________________________________________________________________
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3. ANSWER: ________
RATIO:________________________________________________________________________________________
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4. ANSWER: ________
RATIO:________________________________________________________________________________________
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5. ANSWER: ________
RATIO:________________________________________________________________________________________
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LESSON WRAP-UP

You will now mark (encircle) the session you have finished today in the tracker below. This is simply a visual to help you
track how much work you have accomplished and how much work there is left to do.

You are done with the session! Let’s track your progress.

AL Activity: CAT: MINUTE PAPER

This strategy provides feedback on whether or not you understand the lesson. Use the space provided in this activity
sheet to answer the following questions. Make sure to not miss a tiny detail!

What do you think is the most cost efficient and effective way in preventing diabetes mellitus? Explain.

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