Carbohydrate-Controlled

Diets for Diabetes Mellitus

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(caused by the exposure of eye tissues to hyperosmolar
fluids)
• ❚ Increased infections(due to weakened immune responses and
impaired circulation)
• ❚ Fatigue(due to altered energy metabolism, dehydration, or other
effects of illness).
• Symptoms of diabetes are usually related to the degree of
hyperglycemia present.
• When the plasma glucose level rises above about 200
milligrams per deciliter (mg/dL), it exceeds the renal
threshold, the concentration at which the kidneys begin to
pass glucose into the urine (glycosuria).
• The presence of glucose in the urine draws additional water
from the blood, increasing the amount of urine produced.
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.
Diabetes - Related Symptoms and
Complications
• Individuals with prediabetes have blood glucose levels that
are above normal but not high enough to be classified as
diabetes; these individuals are at high risk of eventually
developing type 2 diabetes and cardiovascular diseases.
Types of Diabetes
• two main types of diabetes, type 1 and type 2 diabetes.
• Pregnancy can lead to abnormal glucose tolerance and the
condition known as gestational diabetes, which often
resolves after pregnancy but is a risk factor for type 2
diabetes.
• Diabetes can also be caused by medical conditions that
damage the pancreas or interfere with insulin function.
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.
• People with type 1 diabetes often have a genetic
susceptibility for the disorder.
• Type 1 diabetes usually develops during childhood or
adolescence.
• 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.
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.
• 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.
• Genetic factors strongly influence risk type 2 diabetes.
• ketone bodies: products of fat metabolism that are
produced in the liver; accumulate in the blood when
abnormally high amounts of fatty acids are released from
adipose tissue.
• type 2 diabetes: diabetes that is characterized by insulin
resistance coupled with insufficient insulin secretion.
• insulin resistance: reduced sensitivity to insulin in muscle,
adipose,and liver cells.
• hyperinsulinemia: abnormally high levels of insulin in the
blood.
Type 2 Diabetes in Children and Adolescents
• 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.
• Type 1 and type 2 diabetes are sometimes difficult to
distinguish in children,
Acute Complications of Diabetes Mellitus
1. Diabetic Ketoacidosis in Type 1 Diabetes
2. Hyperosmolar Hyperglycemic Syndrome in Type 2
Diabetes.
3. Hypoglycemia
Diabetic Ketoacidosis in Type 1 Diabetes
• A severe lack of insulin causes diabetic ketoacidosis.
• 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).
• The main features of diabetic ketoacidosis therefore include
severe ketosis, acidosis, and hyperglycemia.
• Patients with ketoacidosis may exhibit symptoms of both
acidosis and dehydration.
• 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.
• 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.
Hypoglycemia
• low blood glucose, is due to the inappropriate management
of diabetes rather than the disease itself.
• It is usually caused by excessive dosages 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.
• Symptoms of hypoglycemia include sweating, heart
palpitations, shakiness, hunger, weakness, dizziness, and
irritability.
Chronic Complications of Diabetes
1. Macrovascular Complications : involve the large blood
vessels . atherosclerosis in the arteries of the heart, brain,
and limbs.
• 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.
2. Microvascular Complications : smaller vessels such as
arterioles and capillarie.
• 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.
3. Diabetic Neuropathy
• deep pain or burning in the legs and feet, weakness of the
arms and legs, or numbness and tingling in the hands and
feet.
• Another type of diabetes is called gestational diabetes. This
type of diabetes only occurs during pregnancy. After delivery
of the baby, blood glucose returns to normal. Women who
have gestational diabetes are at a higher risk for type 2
diabetes. Meal planning, exercise, and possibly medication
are used to control blood glucose during pregnancy.
CONSISTENT CARBOHYDRATE DIET
• This diet follows the principles of the General Diet but
provides consistent carbohydrate intake at meals.
The goals of nutrition therapy in treating
diabetes are:
1. Maintain as near normal blood glucose levels as is safely possible.
2. Achieve optimal serum lipid levels (cholesterol, HDL and LDL
cholesterol, and triglycerides) and blood pressure levels to prevent
and treat cardiovascular disease.
3. Provide adequate energy to achieve and maintain a reasonable body
weight in adults and to support growth during pregnancy and
childhood.
4. Prevent and treat short-term complications such as hyperglycemia
(high blood sugar) or hypoglycemia (low blood sugar) and long-
term complications such as renal (kidney) disease, cardiovascular
disease, neuropathies (nerve damage), and amputation.
5. Improve overall health by encouraging healthy food choices and
maintain the enjoyment of eating by restricting food only when
supported by science.
Diet Principles
• Individualization. Individualization of treatment for patients
with diabetes is essential. The effect of medical nutrition therapy
on blood glucose and serum lipid levels (especially triglycerides
and LDL cholesterol) must be evaluated and modified. The plan
should be sensitive to cultural, ethnic, and financial
considerations.
• Energy. The caloric value of meal plans must provide adequate
energy to achieve and maintain a desirable or reasonable weight.
Weight reduction of 5 to 10% of initial body weight may improve
blood glucose levels as well as blood pressure in many obese
people with type 2 diabetes. For individuals with diabetes that
are within a desirable weight range, caloric intake must match
expenditure to maintain normal weight. For the person below
desirable weight, caloric intake must allow for appropriate
weight gain.
• Carbohydrate. Carbohydrates include sugars and starches.
They are digested into glucose (blood sugar) all of the time.
• In a person that does not have diabetes, the pancreas
releases insulin based on the amount of carbohydrate that is
consumed.
• The DRIs recommends 45 to 65% of total calories from
carbohydrates. Carbohydrates are found in four main groups
of food: (a) starches, (b) fruit and fruit juices, (c) milk and
milk products, and (d) sweets, desserts, and other
carbohydrates.
• Monitoring blood glucose after meals can help evaluate an
individual’s responses and determine if the carbohydrate
level needs to be adjusted, or for those who require
medication, if the dose of medication needs to be adjusted.
• For persons on flexible insulin doses (i.e., insulin-to-
carbohydrate ratios), insulin doses are adjusted based on
the amount of carbohydrate consumed at each meal.
• Protein and Fat. Protein and fat do not affect the blood
glucose directly like carbohydrates do.
• The amount of protein and fat servings do not need to be
consistent from day to day because they have little effect on
blood glucose levels.
• The amount of protein and fat that is provided in the
General Diet is appropriate for the individual with diabetes
in healthcare institutions.
• Exercise. Most people with diabetes benefit from regular
exercise.
• Exercise improves the body’s response to insulin, helps
lower blood glucose levels, and is a key factor in the success
of clients achieving and maintaining a desirable or
reasonable body weight.
• Individuals using insulin may need adjustments to their
meal pattern to prevent hypoglycemia during or after
strenuous activity.
• Reducing Cardiovascular Risk: Because the diagnosis of
diabetes is a single risk factor for cardiovascular disease,
controlling blood lipid levels is an important treatment
goal. Saturated fat should be limited to less than 7% of total
calories and trans fat should be minimized.
• Total cholesterol intake should average less than 200
mg/day.
• Plasma triglyceride response to high carbohydrate diets
(≥55% calories from carbohydrate) in individuals is quite
variable.
• Some people have improvements in triglycerides when
monounsaturated fats are substituted for a portion of the
carbohydrates.
• Meal Patterns. Food, exercise, and insulin or oral
hypoglycemic agents influence blood glucose concentration.
• These three influences need to be considered in various
ways in the treatment of diabetes.
• Exercise reduces the need for insulin and increases the need
for carbohydrate.
• regular pattern for taking insulin injections, meals and
snacks, and exercise can be worked out so that both
hyperglycemia and hypoglycemia can be minimized
• Measuring Food. Food should be measured with standard
measuring equipment .Foods are measured after they are
cooked.
• Special Foods. Special foods are not necessary and may be
expensive.Foods labeled “sugar-free,” “no sugar,” “reduced
sugar,” or “lower sugar” may be high in fat, calories, and
even carbohydrates.
Menu Planning
• the amount of carbohydrates consumed is consistent and
the time of the meals and snacks are consistent as well.
• This pattern will help promote optimal blood glucose
control.
• Carbohydrate counting is based on choices or grams per
meal and snack.
• The individual is given a carbohydrate allowance that has
been individualized to their nutrition therapy and blood
glucose goals.
• One carbohydrate choice equals 15 grams of carbohydrate.
• Meal plans may vary from three to five choices (45–75
grams) of carbohydrates per meal and one to two choices
(15–30 grams) of carbohydrates per snacks.
• most individuals need an evening snack.
• not all choices have the same nutritional value and may alter
overall nutrition status of the individual.
• 1000 kcal /4 = ……. Grams of CHO
• Grams of CHO /15 = exchanges of CHO “ CHO choices “
• the carbohydrate choices adjusted based on the
carbohydrate allowance for that patient.
• The following menu shows an example of adapting a
General Diet to a Consistent Carbohydrate Diet providing
about 2,000 calories per day.
Gestational Diabetes Meal Plan
• The meal plan for a woman with gestational diabetes follows
the same principles as the Consistent Carbohydrate Diet.
• Total carbohydrate intake is usually 40 to 45% of total
calories.
• the minimum amount of carbohydrate recommended daily
in pregnancy is 175 grams according to the DRIs.
• provide enough calories in the meal plan to promote proper
weight gain and prevent starvation ketosis
• extra protein and fat foods at each meal and snack time can
aid in meeting calorie needs.
• The meal pattern for breakfast is reduced in carbohydrates
due to hormonal surges and insulin resistance in the
morning hours.
• The carbohydrate allowance for breakfast is limited to two
choices (30 grams) to help promote optimal blood glucose
levels.
2000 Kcal diet
for gestational
diabetes
• Once the meal plan is in place, blood glucose is checked on
a regular basis.
• If the blood sugars show a trend of acceptable readings, the
meal plan may be adjusted to a higher carbohydrate
allowance.
• This generally does not occur with many women with
gestational diabetes due to hormonal changes during
pregnancy.
Full and Clear Liquid Substitutions
• When an individual with diabetes cannot eat solid food, it
may be necessary to offer the Clear Liquid or Full Liquid
Diet.
• Carbohydrate counting still plays a role with meal planning.
• Individuals should receive approximately 200 grams of
carbohydrate daily.
Table shows carbohydrate values for selected foods
that could be offered on a Full or Clear Liquid Diet.
Hypoglycemia
• Hypoglycemia or low blood sugar can be caused by taking
too much diabetes medication, eating too few carbohydrates
at meal time, skipping meals, or getting more exercise than
usual.
• Common signs are feeling shaky, sweaty, tired, hungry,
crabby or confused, rapid heart rate, blurred vision or
headaches, and numbness or tingling in the mouth and lips.
• In severe cases, the person may lose consciousness.
• The treatment for low blood sugar is the “Rule of 15.” This
means once a low blood sugar is recognized, 15 grams of
carbohydrate are given.
• It is recommended to use only carbohydrate to treat
hypoglycemia and not to use foods high in protein or fat.
• Protein can stimulate the pancreas to release insulin and
does not prevent a repeat low blood sugar.
• Fat slows down the absorption of carbohydrate leading to a
delay in raising blood glucose.
• The blood sugar should be rechecked in 15 minutes. If the
blood sugar remains low, then retreat with 15 grams of
carbohydrate.
• Recheck the blood sugar again in 15 minutes and repeat as
necessary until the blood sugar is within normal limits.
• If the next meal is more than one hour away, serve a snack
consisting of 30 grams of carbohydrate.
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.
Insulin Preparations
• The forms of insulin that are commercially available differ
by their onset of action, timing of peak action, and duration
of effects.
• 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.
• 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.
• Insulin pens
Insulin Regimen for Type 1 Diabetes
• Type 1 diabetes is best managed with intensive insulin
therapy, which typically involves three or four daily
injections of several types of insulin or the use of an insulin
pump.
• Insulin pumps are usually programmed to deliver low
amounts of rapid-acting insulin continuously (to meet basal
insulin needs) and bolus doses of rapid-acting insulin at
mealtimes.
• In persons who inject insulin, intermediate- or long-acting
insulin meets basal insulin needs, and rapid- or short-acting
insulin is injected before meals.
• The amount required depends on the pre-meal blood
glucose level, the carbohydrate content of the meal, and the
person’s body weight and sensitivity to insulin.
• To determine insulin sensitivity, the individual keeps careful
records of food intake, insulin dosages, and blood glucose
levels.
• these records are analyzed by medical personnel to
determine the appropriate carbohydrate-to-insulin ratio for
that individual, which assists in calculating insulin dosages
at mealtime.
Insulin Regimen for Type 2 Diabetes
• Some regimens involve a mixture of intermediate-acting
and rapid- or short-acting insulin
• in the morning and an injection of intermediate- or long-
acting insulin at dinner or before bedtime. In other cases,
only a single injection of intermediate- or long-acting
insulin may be needed at bedtime.
• Doses and timing are adjusted according to the results of
blood glucose self-monitoring.