Chapter 16:

DIET THERAPY FOR

DIABETES MELLITUS AND
RENAL DISORDERS
Reporters:
Ayari, Yassin
Bacarro, Maria Carmen
Bioco, Precious Diane
 DIABETES
Is a metabolic disorder that can strike at any age. It affects not only
carbohydrate, but also protein and fat utilization.
It is a serious health problem data from the International Diabetes, indicating
a worldwide epidemic of diabetes. Data from the International Diabetes Federation
show that in 2007, the worldwide prevalence rate averaged about 6%, and
projected 10 increase to 7.3% by 2025. The actual percentage may be higher
because many persons are not diagnosed unless they have a medical check-up.
Diabetes is the leading cause of blindness, cardiovascular disease, leg and
foot amputations, and kidney Failure. About 5 out of 10 Filipinos are at great risk
of developing diabetes. Both severe are equally affected; majority of cases are 40
years and above.
 01
CLASSIFICATION
AND DIAGNOSIS
OF
DIABETES
The classification of
diabetes includes four
clinical classes:

Gestational diabetes
Type 1 diabetes mellitus mellitus
results from beta-cell destruction, usually diagnosed during pregnancy
leading to absolute insulin deficiency.
Other specific types of
diabetes
Type 2 diabetes mellitus due to other causes, e.g, genetic defects in beta
cells chemically induced DM, function,
results from a progressive insulin secretory
genetic defects in insulin action, diseases of
defect on the background of insulin
the exocrine pancreas, drug.
resistance.
 02
PATHOGENESIS,
SIGNS AND SYMPTOMS
IN DIABETES
 In diabetes, the microscopic islets of Langerhans of the B-
cells of the pancreas produce little or no insulin. Insulin is a
hormone that helps the body tissues absorbs glucose so it can
be utilized as a source of energy to fuel cellular functions.
The condition may also develop insulin resistance; muscle
and fat cells respond poorly to insulin. Because of the problem
in insulin amount and/ or function, glucose levels build up in
the blood and
urine, causing various manifestation.
 Classical Symptoms of Diabetes
Mellitus
CLASSICAL/ ATYPICAL COMMENT
Elevated Blood Sugar Occurs when there is no appropriate level of insulin to help
(Hypergycemia) glucose enter the cells or insulin action is not recognized by cell’s
receptors.

Increased Hunger Glucose is not utilized by the cells, which signal the need for
(Polyphagia) glucose.

Frequent Urination Kidneys have to get rid of excess glucose accompanied by loss of
(Polyuria) water and electrolytes.

Increased Thirst This triggers the need for replacement of water lost in the urine.
(Polydipsia)
CLASSICAL/ ATYPICAL COMMENT

Sugar in the Urine Excess glucose spills into the urine (urine threshold – 180mg/L
(Glycosuria)

Dramatic weight loss Cells do not receive enough glucose for energy and storage
and weakness

Fluctuation in visual Due to hyperglycemia affecting the circulation in the eye.

acuity

Delayed wound healing Protein utilization is decreased.

Susceptibility to
Immune system is affected.
infections
Type 1 Diabetes Generally occurs in young, lean
Mellitus patients and is characterized by a
marked inability of the pancreas to
secrete insulin and dependent on
exogenous source of insulin to sustain
their lives. Without insulin, cells in the
body cannot take enough amounts of
sugar to perform their everyday jobs.
This results in abnormally high levels of
sugar in the blood leading to gradual
deterioration of some organs and
decreased life span of around 1S years.
Since the body cannot convert glucose
to genesis
 (Previously called adult-onset
Type 2 Diabetes diabetes or non-insulin dependent DM) is a
form of diabetes that results from the
Mellitus body's inability to make enough or properly
use insulin. It is the most common form
accounting for 90-95% of diabetes.
Three major metabolic defects that
contribute to hyperglycemia and type 2 DM
use 1) increased glucose production by the
liver; 2) impaired insulin secretion by the
pancreatic islet cells; and 3) insulin
resistance in skeletal muscles. The disease
usually appears after the age of 40, and
many type 2 diabetics are not aware they
have the disease until severe symptoms
occur or they are treated for one of its
serious complications.
 Gestational
Diabetes Mellitus
Is a carbohydrate intolerance of
variable severity with onset of recognition
during the present pregnancy. It is typically
diagnosed during the 3 trimester and is
related to the metabolic changes during
pregnancy. All women should be routinely
screened for DM between the 24 and 28
week of pregnancy
OGTT NORMAL VALUES DURING
PREGNANCY
TIME PLASMA GLUCOSE LEVEL

FASTING Less than 95 mg/dL (5.3 mmol/l)

1 HOUR Less than 180 mg/dL (10 mmol/l)

2 HOURS Less than 155 mg/dL (8.6 mmol/l)

3 HOURS Less than 140 mg/dL (7.8 mmol/l)

 03
METABOLISM IN
DIABETES
MELLITUS
 Role of Insulin

Normally, insulin signals the

body that it has been fed and directs
cellular activities that favor the
storage of protein, carbohydrate and
fat. Specifically, insulin stimulates
glucose utilization in skeletal
muscles, heart and some other
tissues.
 Carbohydrate
Metabolism

In patients with uncontrollable

diabetes, there is an abnormal increase
in blood sugar level due to the absence
of or inefficient functioning insulin. The
basic problem in diabetes is that glucose
is unable to get into the cells, resulting
in disturbance.
 Fat Metabolism

Fatty acid synthesis in DM decreases

resulting in lipogenesis (fat formation)
while fatty oxidation increase lipolysis (fat
breakdown). Glycogen stores of the liver
are depleted with the failure to synthesize
glycogen and to utilize glucose.
 Protein
Metabolism

Accelerated breakdown of tissue protein

also occurs in uncontrolled DM, which adds
to the glucose level of the blood and increases
the amount of nitrogen that must be excreted
as a result of deamination. The catabolism of
protein tissues is accompanied by the release
of cellular potassium and its excretion in the
urine.
 04
DIAGNOSTIC
AND
MONITORING
TESTS
 Fasting Blood Sugar
Test Glucose Tolerance Test
is made after extracting venous blood is a measure of the ability of the patient
from the patient who has fasted for at least to utilize a specific amount of glucose. It
12 hr. A fasting blood sugar (FBS) of more is used to establish a diagnosis of
than 126 mg per 100 ml on more than one diabetes or impaired glucose tolerance in
occasion is indicative of diabetes. asymptomatic individuals whose FBS is
between 110 and 140 mg/dL of plasma.
 Glycosylated Self Monitoring Blood
Hemoglobin (HbA1C) Glucose (SMBG)
allows persons who have diabetes to
provides a good index for
measure their blood glucose at home,
monitoring overall diabetes control and
adjust treatment regimens as needed, and
therapeutic decisions can be based on this
achieve near-normal blood glucose levels.
value. Patients with HbA1C of >6.5%
Improvement in glycemic control through
require pharmacological treatment while
intensive insulin therapy and self-
those with HbAIC of ≤6.5% can generally
monitoring of blood glucose, significantly
be treated with diet and exercise.
reduce micro vascular complications of
DM.
 pto m s of
Sym evels o
f
m a l L
Abnor d Sugar
Bloo

Hyperglycemia Hypoglycemia
 Dehydration  Anger
 Desire to drink  Blurred vision
excessive fluids  Confusion
 Dry mouth  Fearfulness
 Fatigue  Headache
 Low blood pressure  Lack of coordination
 Low grade fever  Palpitations
 Polyuria  Sweating
 Weight loss  Tremors
 05
COMPLICATION
S
 Hypoglycemia or Hyperglycemia/ Diabetic
Insulin Shock Ketoacidosis

This is not a disease but a symptom of Diabetic ketoacidosis (DKA) is due to

abnormalities in carbohydrate metabolism. Here, severe hyperglycemia. This occurs when the

there is significant increase in available glucose person with diabetes has inadequate insulin due

due to delay in eating, omission of food, or loss to omission of insulin or consumption of more

of food by vomiting and diarrhea, or due to an food than the insulin prescribed. As a result, the

increase in exercise without modification of body depends on fat for energy and ketones are

insulin dosage. formed. These ketones spill into the urine, and
the individual can test the urine for ketones. If
untreated, DKA can lead to coma and death.
 06
LONG TERM
COMPLICATION
S
 Diabetic Retinopathy

Affects the back of the eyes

where visual images are conveyed
to the brain. Very tiny, fragile blood Diabetic Cataract
vessels proliferate in this area,
A specific type of opacity of the
which is detected by dilated eye
lens occurs when diabetes has not
examination, hence the need for
been adequately controlled. This
regular eye check-up.
problem in vision occurs commonly in
elderly diabetes and rarely in children.
 Diabetes Neuropathy Diabetic Gastroparesis

Can occur in any part of the body, but The other set of nerves commonly
especially periphery nerves, as in the feet and
affected in uncontrolled DM involves the
legs. The lesions of the nerves cause burning and
gastrointestinal tract and the condition is
tingling sensations, and numbness or no feeling
called gastroparesis. There is partial
at all in severe cases. Daily inspection of the feet
and proper hygiene and care should be practiced. paralysis of the nerves leading to the
Persons with diabetes are advised to a podiatrist muscles of the stomach. This needs
for pedicure. They should wear socks or enclosed nutrition therapy similar to GERD
shoes to avoid any harm.
 Periodontal Disease
Occurs in Type 2 DM more often
Cardiovascular
than in Type I because saliva production is
Disorders
diminished with aging especially when
Include silent heart attacks,
water drinking is inadequate. In both
orthostatic hypertension, and impotence
types of DM, inflammation of the gums
or erectile dysfunction. Permission from
when dental plaque builds up causes
the physician about an exercise program
periodontal disease.
is important, because the heart may not be
able to cope with pumping oxygen supply
needed for some exercises.
Diabetes Skin Lesions
Any damage to the skin of the Diabetes Foot
diabetic patient either heals; very slow or The diabetic foot is a manifestation of
never heals. Very often, a gangrenous chronic neuropathy, aggravate, in many
condition develops at the site of injury. cases by vascular insufficiency and
Atherosclerosis and poor circulation of the infection. Sensory loss allows tolerance y
blood are causative factors for delayed repeated trauma from light shoes and
healing. improper weight bearing, which leads to
the breakdown, skin ulceration, tissue
necrosis, and fracture.
SUMMARY OF LONG TERM COMPLICATIONS OF
DIABETES MELLITUS
 07
MANAGEMENT
OF DIABETES
 1. Insulin or oral hypoglycemic agents (compliance with
MD's prescribed drugs: kind, dose, and time to take each)
2. Healthy eating; (eat at regular times of the proper kind and amount
of food and beverages, including water, as instructed by an RND)
3. Regular exercises suitable for one's medical condition. Observe the kind,
duration and intensity.
4. Avoid stress factors. Controllable types are anger and other emotional
causes, adequate rest and sleep, financial problems, unnecessary worries,
environmental factors like sanitation and safety, fresh clean air.
Uncontrollable factors include one's genotype or genetics, some medical
conditions of unknown etiology, some emotional problems
unless one seeks professional/psychiatric help.

Basic Control
Of Diabetes
rest on a balance
of four important
factors:
 Diabetes Self- Management
Education (DSME)
Is the ongoing process of facilitating the knowledge, skill and ability necessary for diabetes
self-care. Content areas for DSME are the following:
• Describing the diabetes disease process and treatment options
• Incorporating nutritional management into lifestyle
• Incorporating physical activity into lifestyle
• Using medications) safely and for maximum therapeutic effectiveness
• Monitoring blood glucose and other parameters and interpreting and
using the results for self-management decision making
• Preventing, detecting, and treating acute complications
• Preventing detecting, and treating chronic complications
• Developing personal strategies to address psycho-social issues and concerns
• Developing personal strategies to promote health and behavior change.
Summary table of Insulin Preparations
in the Philippines
 1. Animal
2. Human ( not from
Three groups humans but produced
alphabetically to match human
of Insulin insulin)
3. Analogues
 SIX M
TYP AIN
ES O
1. Rapid-acting analogues can be injected just before, with or after INSU F
food and have a peak action at between 0 and 3 hours.
LIN:
They tend to last between 2 and 5 hours and only last long enough
for the meal at which they are taken. They are clear in appearance.
2. Long-acting analogues tend to be injected once a day to provide
background insulin lasting approximately 24 hours. They don't need to be taken
with food because they don't have a peak action. They are clear in appearance.

3. Short-acting insulin should be injected 15-30 minutes before a meal to cover the rise in blood
glucose levels that occurs after eating. They have a peak action of 2-6 hours and can last for up
to 8 hours. They are clear in appearance.
 SIX M
TYP AIN
ES O
INSU F
LIN:
4. Medium- and long-acting insulin are taken once or twice a day

to provide background insulin or in combination with

short-acting insulin/rapid-acting analogues. Their peak activity is between 4 and 12 hours and
can last up to 30 hours. They are cloudy in appearance.

5. Mixed insulin is a combination of medium- and short-acting insulin.

6. Mixed analogue is a combination of medium-acting insulin and rapid-acting analogue.

 08
DIETARY
MANAGEMENT
OF DM
 ENERGY PROTEIN
ALLOWANCE ALLOWANCE
After the caloric allowance has been
The actual weight of the patient should
be the object of careful analysis and determined, the protein allowance of the
control of in energy intake to attain
patient is then established. Again, the
desirable or reasonable body weight
should be the prime objective. The diet desirable body weight of the patient is used
should be one which will supply sufficient
as the basis for the calculation. The protein
energy to maintain attain the desired
weight taking into account the patient's allowance for the diabetic patient is, in
activity and lifestyle.
general, the same as that of the normal
individual.
 CARBOHYDRATE
ALLOWANCE
The estimation is guided by the FAT ALLOWANCE
patient's blood sugar, urinalysis data and Fat intake should be individualized
available insulin. For normal adults, according to the client's health, goals.
carbohydrates provide 50-70% of total Recommendation is usually 25-30% of
energy requirement. In diabetic patients, total calories; however higher amount
the range of carbohydrate intake should be can be given but should not exceed 35%
45-65% of total calories. Foods containing of the local calories.
carbohydrates from whole grains, fruits,
vegetables and non-fat dairy products are
emphasized.
 Diabetes Meal Plan
VITAMINS AND
Is a guide that tells a patient how
MINERALS much and what kinds of food he can
Those with poorly controlled diabetes, choose to eat at meals and snack times. A
good meal plan should fit in with his
patients on extremely restricted diets, schedule and eating habits. People with
vegetarians, the elderly, pregnant or diabetes have to take extra care to make
sure that their food is balanced with insulin
lactating mother, those taking and oral medications, and exercise to help
medications known alter micro nutrient manage their blood glucose levels.

metabolism, and patients in critical care

environment may require vitamin and
mineral supplementation.
 FOOD
DISTRIBUTION

Distribution of meals and snacks

depends on individual lifestyle and activity
patterns and is based on assessment data.
With consistent food intake from day-to-
day, insulin therapy can usually be adjusted
to match the patient's customary food
intake.
 ARTIFICIAL
SWEETENERS

These can be used by people with

diabetes and may help to
control calorie intake as these
sweeteners do not affect blood
sugar levels.
 EXERCISE
In addition to diet and insulin, exercise helps
regulate diabetes by promoting glucose utilization and
improving blood circulation. A regular exercise
(continuous activity lasting at least 20-30 minutes and
performed at least 3-4 days a week) has been shown to
promote weight loss, improve insulin sensitivity, and
sometimes glucose tolerance in individuals with both
types of DM. People with diabetes are encouraged to
participate in either recreational or competitive physical
activities because of potential to improve cardiovascular
fitness and psychological well-being and for social
interaction and recreation as well.
 09
DIABETES
AND
SURGERY
 To be able to withstand surgical
procedures, the diabetic as well as the
non-diabetic individual should have a
good store of glycogen. Sufficient food
of high carbohydrate content and
sufficient insulin to oxidize the
carbohydrate should be given up to 12
hours before operation. Fluids should
be given in abundance. In emergency
operations where coma and acidosis are
more likely to occur, it is necessary to
give parental glucose and saline.
 10
MANAGEMENT
OF DIABETES
IN PREGNANCY
 Particularly during the last
half of pregnancy, the diabetic
pregnant woman requires an
increase in the diet similar to those
of the non-diabetic pregnant
woman, and a corresponding
adjustment of insulin dosage. Oral
medication are not prescribed.
Diabetes increases the hazards of
pregnancy because of dangers of
glycogen depletion, hypoglycemia,
acidosis, and infection.
 11
DIETARY
GUIDELINES
FOR
GESTATIONAL
DIABETES
 12
MANAGEMENT
OF DIABETES
IN CHILDREN
 ● Protein. It is important to maintain
● Insulin Treatment. Requirement of protein intake for children with
the child are often variable, due to diabetes.
their fluctuating activities which ● Carbohydrates and Fat. To help
vary from sedentary to very active. reduce the risk of cardiovascular
● Diet Therapy. A major nutrition disease, the lipid levels should be
goal for children and adolescents monitored regularly
with type 2 diabetes is maintenance ● Minerals and Vitamins. Diabetic
of normal growth and development. children and adolescent need
● Energy. It is important to maintain utmost care, the diabetic diet should
energy allowance to maintain be generously supplied with the
desirable rate of growth. needed vitamins.
 13
RENAL
DISORDERS,
ETIOLOGY AND
PROGNOSIS
● Etiology. Most human kidney
disease are characterized by an
initial injury, followed by
progression of renal lesions.
● There are 2 groups of renal
disorders: acute renal failure (ARF)
which involves a sudden decline in
kidney function and chronic renal
failure (CRF) the deterioration of
kidney function, which progresses
over a prolonged period towards a
fetal termination.
● Prognosis. The dreaded
consequences of CKD is end-stage
of renal disease requiring dialysis or
transplantation.
 14
MANAGEMENT
OF RENAL
DISORDERS
 Kidney ailments are commonly
treated by good fluid intake, a
modification of diet rich in vegetables
and fruits, and an active lifestyle. The
nutritional management of patients with
renal disease focuses on the intake of
calories, protein, sodium, potassium,
phosphorous, and fluids. In order for
patients with permanently damaged
kidneys to survive, they require renal
replacement therapy (RRT), either in the
form of dialysis or as renal
transplantation.
 15
ACUTE RENAL
FAILURE
Acute renal failure can be
caused by toxic injury to
the kidneys, severe
hemorrhage, after burns,
injuries, shock,
transfusions, and
antibiotics.
 16
CHRONIC
KIDNEY DISEASE
 CDK is frequently caused by
diabetes,
glomerulonephritis, long-
tern hypertension, chronic
infections, tubular disease,
chronic hypercalcemia,
chronic hyperkalemia renal
neoplasms, collagen disease,
genetic defects, and abuse of
analgesics.
 ENERGY PHOSPHORUS
dietary phosphorus restriction
patients with renal failure need
must be prescribed at all stages of
adequate energy to maintain or achieve
renal failure in adults
desirable body weight and to prevent
protein catabolism. FLUID AND
ELECTROLYTES
PROTEIN
The damaged kidney cannot handle
The amount of urea nitrogen and too much water so extra care must
creatinine in the blood is a gauge of be observed to avoid water
the severity of renal damage. intoxication from overloading or
dehydration from too little fluid
intake.
 VITAMINS AND
POTASSIUM MINERALS
Uremic patients are often deficient in
Most people with renal failure do not
water soluble vitamins because of:
have problems handling typical intakes
1. Poor intake of nutrient dense food
of potassium
sources and dietary restrictions
2. Losses during dialysis
3. Altered metabolism due to drugs
and/or anemia
 17
UROLITHIASIS
The causes of urolithiasis or kidney
stones in general are a very high
concentration of certain chemicals and
various salts in the urine that results in
crystal formation. This may be
brought about by heredity, excess of
calcium and other minerals in the diet;
intake of excess uric acid, certain
medications, Vitamins C & D; diet in
oxalate; long-term dehydration and
urinary infection.
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