Nutricare in Diabetes With Special Conditions

8/6/2019 Nutricare in Diabetes With Special Conditions

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NUTRICARE IN

DIABETES WITHSPECIAL CONDITIONS

PREGNANCY

ILLNESS

SURGERY

GERIATIC POPULATION

NUDRAT KHAN

Jr.M.Sc CND


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PREGNANCYAND DIABETES

GESTATIONAL DIABETES

Diabetes developed during pregnancy

PRE-GESTATIONAL DIABETESDiabetes predates pregnancy


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GESTATIONAL DIABETES (GDM)

Defined as glucose intolerance of

variable severity with onset or first

recognition during pregnancy.

It occurs in the latter stage of

pregnancy, usually developing

around the 24-28 weeks of pregnancy


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PATHOPHYSIOLOGY

Normal Pregnancy Maternal Metabolic

Adaptationy Diabetogenic state changes in carbohydrate

metabolism + physiological Insulin Resistance

y Hormones ofPregnancy Peripheral InsulinResistance

y Insulin needs doubled or tripled by the time of

delivery

y Pancreas respond by releasing more Insulin to Overcome Insulin Resistance


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PATHOPHYSIOLOGY (CONT.)

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.

y Triggered by an Antigenic Load(Fetus)HLA-G is postulated to protect pancreatic islet cells.

Interaction between HLA-G and NF-B lead to GDM

development.


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PATHOPHYSIOLOGY (CONT.)

Rare cause ofGDMautoimmune destruction ofpancreatic -cells.

characterized by circulating anti-islet cell antibodies or

-cell antigens such as glutamic acid decarboxylase,

GAD, or insulin autoantibodies, IAA.

Seen in


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DIAGNOSTIC CRITERIA FOR GESTATIONAL

DIABETES:

100 gOGTT

is performed in the morning after an overnightfast of at least 8 hrs

Two of the above Values must be met or exceeded for a

diagnosis of gestational diabetes to be made.

TABLE 1: Diagnostic Criteria for

Gestational Diabetes

100 g OGTTFasting 95 mg/dl

1-hour 180 mg/dl

2-hour 155 mg/dl

3-hour 140 mg/dl

Source: ADA, 2008


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RISKOF GESTATIONAL DIABETES

MATERNAL RISKARE:-

HypertensionPolyhydramnios

Caesarian section

RISKTOBABYARE:-Macrosomia- >4kg or >90th percentile

y Common complication of vaginal birth like Shoulder dystocia.

Neonatal

Hypoglycemia

y Risks associated with this condition are seizures, cerebral

damage and rarely death.

Other Neonatal Metabolic Problems are Jaundice and

calcium or magnesium imbalance.


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RISKINTHE FUTURE

To the Mother are:-

T2Dy Risk Factor Obesity & Family History

y Screened at 6-12 weeks post-partum and every 3years.

y Maintain Normal BMI and Activity of 150mins/week to prevent development ofT2D.

GDM in subsequent pregnancies

To the Baby are :-Obesity & Glucose Intolerance in late adolescence and

early Adulthood


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MANAGEMENT STATEGIES

Regular monitoring ofBlood glucose at least 4 times a

day(fasting & 1 or 2 hour post prandial) & maintainingwithin target range.

MNT should be initiated immediately upon diagnosis.

SMBG should be initiated immediately after diagnosis is

made. All SMBG and urine ketone results should be

recorded. This helps in modifying the treatment plan.

The following Target Goals are suggested ADA Recommends

y 95 mg/dl, fasting

y 140 mg/dl, 1 hour postprandial

y 120 mg/dl, 2 hour postprandial


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MANAGEMENT STATEGIES (CONT.)

Ketones should be tested if the glucose levels is >200 mg/dl orit the women is sick.

One study found out the a positive correlation between thepresence of ketones and low intelligence score in children( Rizzoet al.,1991)

Measurement of fetal abdominal circumference early in the

third trimester may rule out excess macrosomia risk.

EXERCISE

y Advised to do regular low impact physical activity.

y Avoid high impact or strenuous exercise to induce premature labor.

y Exercise may induce hypoglycemia if the women is treated withinsulin. Check blood glucose before and after exercise tounderstand the impact of exercise and action needed to preventhypoglycemia.

y Exercise after meals may improve the postprandial blood glucose

levels.


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MANAGEMENT STATEGIES (CONT.)

INSULIN

If it is not possible to maintain blood glucose at target

levels for pregnancy within a short time after

diagnosis, the women should be started on Insulin.

ORALGLUCOSE MEDICATION

OHAare not routinely used in pregnancy. There are

some studies which show they may be safe to use but

because of concerns of teratogenicity and neonatalhypoglycemia it is not generally used.


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PRE GESTATIONAL DIABETES OR

PREGNANC Y IN PREEXISTING DIABETES.

Diabetic women planning pregnancy should ensure they haveHbA1c


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PRE-CONCEPTION CARE AND COUNSELLING

Its implementation has reduced the

perinatal mortality rate & survival rate

for both women n infant improved.

It should began atleast 3-4 months before

pregnancy is planned.

Helps to achieve better glycemic control

before becoming pregnant.


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RISK DURINGPREGNANCY

To the Mother:-y Progression of preexisting complication

y Hypoglycemia in 1st trimester.

y Preterm labour

y Polyhydramnios

y Pre-eclampsia

y 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


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RISK AT DELIVERY

To the Mother

y Caesarian section

y Effects ofPre-eclampsia or eclampsia.

To the baby

y Same as for Gestational Diabetes

y Babies are not born with Diabetes.

RISKIN FUTURE:

To Mother-

y Potential Hypoglycemia if energy intake not inc. during Breast

feeding. To Baby

If mother is T1D-

y 25 yrs-1 in 100

If mother has T2D-1 in 7

If both parents have

T2D-1 in 2


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MONITORING

y SBGM and Ketone Testing should be doneregularly

y Recommended Glycemic Targets

Glycemic Target

Prepregnancy

HbA1c(%) 7.0(6.0, if possible)

Once Pregnant

FBG 60-90mg/dl

1-hour PPG


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SURGERY ANDDIABETES

PERIOPERATIVE DIABETES CAREHYPERGLYCEMIA has been identified as a risk

factor for perioperative morbidity and mortality


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Hemodynamic

Instability

Tachycardia

Electrolyte ImbalanceInc. levels of

inflammatory

mediators

Endothelial cell

dysfunctionDefects in immune

function

Increased oxidative

stressProthrombotic

changes

cardiovascular effects

Inc. susceptibility to

infection

Pathophysiology of hyperglycemia in Critically

Ill patients undergoing Surgery


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Surgical Risks and the Benefits of Improved Glucose Control

Source: Rizvi, A.A, Chillag, Chillag, K.J(2010) Perioperative Management of Diabetes and Hyperglycemia in

Patients Undergoing Orthopaedic Surgery. Surgery,J Am Acad Orthop Surg;18:426-435


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Undiagnosed diabetes and hospital-induced hyperglycemia

contribute to increased postoperative complications. They are

at even greater risk than those with preexisting diabetes. &

should be treated in a similar fashion

Because of associated musculoskeletal complications,

patients with diabetes undergo more surgical procedures

than do patients without diabetes.

(NICE-SUGAR) trial in which Intensive and conventional

glycemic control were compared in 6,104 patients in the

intensive care unit. 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.

Increased no. of death at 90 days, in intensive glucose

control as compared with conventional control


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Aconsensus statement of the

AmericanAssociation of Clinical Endocrinologists and

the American Diabetes Association has since

recommended (2009) revising glucose targets

as follows:

In critically ill patients, maintain the

glucose level between 140 and 180 mg/dL.

Greater benefit may be realized at thelower end of this range.

Targets


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PREOPERATIVE MANAGEMENT

Glycemic targets as close as possible to thoseadvocated by the American Diabetes Associationshould be achieved before a planned surgicalprocedure.

These targets include

HbA1C


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INPATIENT HYPOGLYCEMIA

Factors predisposingto hypoglycemia include

advanced age hypoglycemia unawareness or an altered ability to

report hypoglycemic symptoms,

renal insufficiency or dialysis,

liver disease,

malnutrition, sepsis, and CHF.

Use of oral sulfonylurea agents in elderly patients who

are prone to hepatorenal insufficiency,polypharmacy,

or drug interactions may be contributory factors.

Insulin errors and omissions are common. Insulin is

one of the major a high-risk medications in the

inpatient setting


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ILLNESS ANDDIABETES

SICK DAY MANAGEMENT


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SICK DAY MANAGEMENT

Diabetics should be aware that common illnessessuch as cold, flu-like symptoms like vomiting,diarrhoea, sore throat and infection may riseblood glucose levels.

Illnessstressrelease of counterregulatoryhormones to fight infection & liver glycogen isreleased.

Without extra insulin blood glucose willriseDKAor HHS will dev. If enough insulin isnot available.


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SICK DAY RULES

Following these rules may help people with

diabetes prevent the development of DKA orHHS.

1. Drink fluids

y To replace fluids lost through High Blood glucose,fever, vomiting and diarrhoea people should drink

250ml of sugar free, caffeine-free fluids evry hour. Every 3 hours soups that contains sodium.

2. Check Blood Glucose

y Every 2-4 hrs, report high levels to Dr. immediately.

3. Never skip an injection or medication

4. Check urine for ketones

y If bld Glu >240mg/dl

y Presence of ketones should be reported to Dr.immediately.


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GERIATRIC

POPULATIONAND

DIABETES


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EFFECT OF AGING ON GLYCEMIC CONTROL

Geriatric patients face various medical and environmental

problems which make it difficult for them to achieve goodglycemic control.

Reduced food Intake decreased appetite, lack of saliva,reduced taste buds, lack of teeth and gum diseases .Reducedphysical activity and basal metabolic rate.

Reduction in levels of gastric and intestinal enzymes poordigestion and absorption of food.

Malabsorption complicate the dietary and pharmalogicalmanagement of diabetes and predispose to malnutrition.

PHYSIOLOGICAL CHANGES


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Chronic drug administrationy Drug Interaction

y Nutritional deficiency

e.g., metformin causes folate and vitamin B12deficiency.

OrlistatG.I side effectMalabsorption.

Altered thirst perception and delayed fluid

supplementationDehydrationhyperosmolar coma

POLYPHARMACY

DEHYDRATION


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Cognitive dysfunction + loss of memory associated

decrease in compliance with drug therapy.

Ocular complications reduced Visualacuityreduces the effectiveness of visual cues

associated with appetite and hunger.

Co morbid conditions such as arthritis,osteoporosis, spinal disease and muscular disease

reduction in mobility, increase in fall and Injury.

FUNCTIONALIMPAIRMENT


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Loss of first-phase insulin release.

Obese elderly patients Insulin resistance.

Lean elderly patients Impaired glucose-induced insulin

release.

Islet cell antibodies and marked insulin deficiency areincreasingly seen in lean elderly diabetic patients.

Hypoglycemia is often a risk of diabetes treatment in the

elderly.

Glucose counter regulatory hormones responses tohypoglycemia are diminished reduction in autonomic

warning symptoms.

The renal threshold for glucose increases with advanced

age, and glucosuria is not seen at usual levels

ALTERATIONSIN CARBOHYDRATE

METABOLISM


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MANAGEMENT

Goals of therapy for elderly diabetic patients shouldinclude an evaluation of their functional status, lifeexpectancy, social and financial support, and their owndesires for treatment.

Therapy should be chosen based on the individual needsand issues of each patient.

In frail elderly patients, particular attention should begiven to functional goals and to avoiding therapies thatmay cause loss of independence or earlyinstitutionalization.

Restricting caloric intake in longterm care patients

should be done with much caution. Many already haveinsufficient caloric intake because of confusion,dysphagia, and diminished appetite.

When prescribing insulin or oral agent regimens for thispopulation, providers should pay special attention to

possible side effects and drug interactions


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Glucose monitoring equipment should be easy to handle.

Instruction should be given at slow pace along with hand

outs(memory aid).

Make sure that the patient understands how to identify

hypoglycemia. In the elderly, hypoglycemia may manifest

itself solely in terms of neuroglycopenic symptoms

(dizziness, weakness, confusion, delirium)

Taking into consideration personal preference, increasedadherence to plan & better outcome.

A daily multivitamin supplement may be appropriate,

especially for those older adults with reduced energy intake


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EXERCISE

Physical activity attenuate loss of lean body mass,

decrease central adiposity, and improve insulinsensitivity.

Exercise also poses potential risks such as cardiacischemia, musculoskeletal injuries, and

hypoglycemia in patients treated with insulin or

insulin secretagogues.

Elderly diabetic patient should undergo a thorough

medical evaluation before increasing physical

activity.


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FOOT CARE

Alterations in blood flow to the microvascular structures of

the feet, changes in autonomic nervous system function, arethe major causative factors in the pathogenesis of foot

ulcers infection and amputation

Elevated Glucose level

leaching of zinc in urinezincdeficiencyPoor wound healing.

Careful attention to the feet is of paramount importance in

older people with diabetes.

Appropriate foot wear, applications of lipid-based lotions to

dry feet and early intervention when feet lesions occur are

all key factors in the prevention of amputations.


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PHARMACOLOGICAL CONSIDERATION

For lean elderly patients with T2D, agents that promote insulinsecretion should be selected, while in obese elderly patients agents

that lower insulin resistance should be selected.

Alpha-glucosidase inhibitors are modestly effective for glycemiccontrol, but tolerance of these agents is a problem.

Thiazolinediones are effective but associated with an increasedincidence of edema and CHF in the elderly. Should be used withcaution in elderly patients with cardiovascular disease.

Sulfonylreas are effective agents in the elderly, but hypoglycemia

remains the main adverse effect of concern.

Insulin therapy poses special concerns. Dosage errors may resultwith loss of concentration and memory, failing eyesight andmanual dexterity. Use of premixed insulins or prefilled insulin

pens as an alternative to mixing insulins should be considered.


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BIBLIOGRAPHY

India Diabetes Educator Project(2008) DistanceLearning Manual.

Chau.D and Edelman S.V,(2001) ClinicalManagement of diabetes in Elderly, Clinical

Diabetes, Volume 19, Number 4Angela K. M. and Michael A. G.

(2009)Perioperative Glycemic Control,Anesthesiology 110:40821

Ali A.R., Shawn A.C.,KimJ.C,(2010)Perioperative Management of Diabetesand Hyperglycemia in Patients UndergoingOrthopaedic Surgery,J Am Acad OrthopSurg;18:426-435

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