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ON DIABETES: General management strategies for diabetes - Odessa American: News

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ON DIABETES: General management strategies for diabetes

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Posted: Wednesday, August 20, 2014 1:20 pm

Management of diabetes is based upon the symptoms and severity of presentation. Type 2 diabetes mellitus occurs when the pancreas (an organ in the abdomen) produces insufficient amounts of the hormone insulin and/or the body becomes resistant to normal or even high levels of insulin. In contrast, Type 1 diabetes is characterized by destruction of the pancreatic beta cells, leading to absolute insulin deficiency. Ideally, the initial management of Type 2 diabetes should be based on dietary restrictions combined with exercise regimen.

However, pharmacologic therapy like oral hypoglycemic drugs or insulin may be considered, when appropriate, in the presence of high blood glucose level. Using insulin shots or an insulin pump is the only option for Type 1 Diabetes. Having high blood sugar can cause serious problems over time. It can lead to:

  • Nerve damage.
  • Kidney disease.
  • Vision problems (or even blindness).
  • Pain or loss of feeling in the hands and feet.
  • The need to have fingers, toes, or other body parts removed (amputated).
  • Heart disease and stroke. In addition to blood sugar control, aggressive reduction of cardiac risk factors like smoking cessation, blood pressure control, reduction of the bad cholesterol, and use of aspirin should also be considered while treating the patients with type II diabetes.

DIETARY MANAGEMENT:

Dietary modification is very important treatment for diabetes but it also helps with obesity, high blood pressure, and prevention of stroke and heart attack. Weight reduction combined with the calorie restriction leads to the improvement in blood sugar control in majority of diabetic patient if followed rigorously and regularly.

WHEN PLANNING WHAT TO EAT, PEOPLE WITH DIABETES NEED TO THINK ABOUT:

  • Carbohydrates, proteins, and fats: Our bodies break down the food we eat into small pieces called carbohydrates, proteins, and fats. Carbohydrates, which are sugars that our bodies use for energy, can raise a person’s blood sugar level. Your doctor, nurse, or dietitian will tell you how many carbohydrates you should eat at each meal or snack. Foods that have carbohydrates include: bread, pasta, rice, vegetables, fruits.
  • Calories: People need to eat a certain amount of calories each day to keep their weight the same. People who are overweight and want to lose weight need to eat fewer calories each day.
  • Recommended calorie intake: the number of calories needed to maintain weight depends upon your age, sex, height, weight, and activity level.

In general:

  • Men or active women — 15 calories/pound.
  • Most women, sedentary men, and adults over 55 years — 13 calories/pound
  • Sedentary women or obese adults — 10 calories/pound
  • Pregnant or lactating women — 15 to 17calories/ pound.

To lose 1 to 2 pounds per week (a safe rate of weight loss), subtract 500 to 1000 calories from the total number of calories needed to maintain weight. As an example, an overweight man who weighs 300 pounds would need to eat 3000 calories per day to maintain his weight. To lose 1 to 2 pounds per week, he should eat 2000 to 2500 calories per day. As weight is lost, the recommended calorie intake should be recalculated.

RECOMMENDED DIETARY GUIDELINES FOR THE PATIENTS WITH DIABETES:

Out of the total caloric content of the diet in diabetics, Carbohydrates should constitute about 50-60 percent part, protein intake should be in between 10-20 percent of the total energy and the dietary fat should provide 25-35 percent of total intake of calories (saturated fat not more than 10 percent of the total energy with cholesterol restriction up to 300 mg or less daily. Foods with a lot of cholesterol include: red meat, whole milk, and egg yolks). Although carbohydrates used in the diet should be complex and high in fiber (whole grains, fruits with edible skin, vegetables etc.), however the total amount of carbohydrate consumed should be given more importance than its source.

Extra amount of protein (derived from both animal and vegetable source) is recommended for the children and pregnant females because of their increased requirements.

In addition to this, excessive salt intake should be avoided (especially in the patients with associated hypertension and kidney damage). Nutritive sweeteners like sorbitol and fructose should be restricted and the use of artificial sweeteners should be kept to a minimum.

Alcohol should be used in moderation and especially be avoided in diabetic patients with nerve damage, associated lipid abnormalities and those who are taking antidiabetic medications, as the alcohol puts them at increased risk of getting low blood glucose levels. Having more than 1 drink (for women) or 2 drinks (for men) a day can raise blood sugar levels. Also, drinks that have fruit juice or soda in them can raise blood sugar levels.

  • Fiber: Eating foods with a lot of fiber can help control a person’s blood sugar level. Meal timings are very important (specially in those who are taking insulin), therefore the meals should be evenly distributed throughout the day and the consistency of food timings as well as the amount of calorie intake from day to day should be monitored in all the diabetics and dietary counseling should be done by the concerned physicians, Nurses (or dieticians).

EXERCISE AND WEIGHT CONTROL:

Regular physical activity and exercise should be encouraged along with the dietary treatment in all the diabetics, as it promotes the weight reduction, improves the insulin sensitivity, and helps in lowering the blood glucose levels and thereby lowering the dose or even complete stopping of the antidiabetic medications. Although some form of regular exercise is almost always beneficial in most of the diabetics, even those with advanced, long-standing disease, long term compliance is required to achieve the benefits of exercise in lowering the blood sugar levels. We encourage them to perform 30 to 60 minutes of moderate-intensity aerobic activity like brisk walking, doing water aerobics, bicycling on most days of the week.

However, sudden starting of the vigorous exercise regimen in the diabetics with prior sedentary life style should not be done. Rather, an initial regimen with 10 minutes of stretching and warm-up, followed by 20 minutes of gentle aerobic exercise such as walking, cycling, or rowing should be encouraged. The intensity and duration of exercise should then be increased gradually as tolerated along with the education about the appropriate timings of the meal and hypoglycemia.

Exercise stress testing is usually not performed in asymptomatic patients who are following the above mentioned gradual exercise regimen. However, there is an increased risk of asymptomatic coronary artery disease among the diabetics with carotid, coronary or peripheral arterial disease. Therefore, an exercise tolerance test should be considered prior to changing exercise levels in these patients.

Along with the above mentioned advantages, the lifestyle intervention also includes some non cardiac benefits like reductions in urinary incontinence, sleep apnea, depression, and improvements in quality of life, sexual functioning, and individual physical functioning.

As per the recommendations, a weight loss of 10 kg in a patient with the initial value of fasting blood glucose between 108 to 144 mg/dL versus 22 kg if the initial fasting glucose was 216 to 252 mg/dL is required to normalize the fasting blood glucose levels.

Along with this, the weight reduction may also improve liver function in nonalcoholic patients who has fatty liver secondary to their type II diabetes and insulin resistance. However, any degree of weight loss in diabetics is likely to improve blood sugar and thereby resulting in the decrease need for medications. Every 1 percent drop in A1C is associated with significantly improved outcomes.

The surgical treatment (bariatric surgery) of morbidly obese patients with diabetes results in the largest degree of weight loss and improvements in blood glucose readings. However, long term follow-up and trial of weight loss medications is usually done before bariatric surgery procedures can be routinely recommended for the treatment of recent onset, obesity-related type 2 diabetes.

MEDICATIONS:

Although the intensive life style modification like weight reduction, diet, exercise, blood pressure control, and smoking cessation can all be used to improve glycemic control, the majority of patients with diabetes will require medication over the course of their diabetes.

Insulin is preferred in type 1 DM but can also be considered a first-line therapy for type 2 diabetics: if the initial A1C is >10 percent, fasting plasma glucose >250 mg/, random glucose consistently >300 mg/dL or presence of ketones in the urine, or if their blood sugar is not controlled with oral hypoglycemic medications.

MONITORING BLOOD SUGAR CONTROL:

Regular monitoring of blood sugar is very important in diabetes to ensure the disease control, because the absence of symptoms does not mean that the disease is under good control. Therefore, self-glucose monitoring should be done and the frequency of glucose checks should be adjusted based on the type of treatment, therapy target set point, and the severity of the disease and the availability of local treatment facility. Pregnant patient and those on insulin, requires more frequent testing. Methods used are blood glucose testing (by glucometer) which is preferred over urine glucose testing, as it is safe and informative. Other methods include HbA1C testing, urine ketones (especially during the period of illness or poor control).

In addition to selfmonitoring by patients, the blood sugar levels should be verified at the doctor’s office/lab at least every three to six month to ensure the accuracy. Urine glucose testing is only helpful in the situations where frequent blood glucose testing is not possible or refused by the patient or in stable elderly diabetics in whom strict glycemic control is not important. It is not reliable in pregnant diabetics and do not give much information about hypoglycemia.

MANAGEMENT OF DIABETES DURING PREGNANCY:

In all the diabetic women who are planning to become pregnant, Intensive counseling about diabetes and strict glucose control should be done prior to conception. Insulin is the treatment of choice for managing diabetes during pregnancy. Glucose levels should be monitored with frequent follow-ups every 2-4 weeks to ensure glycemic control without significant hypoglycemia. Full clinical assessment including the eye exam, looking for kidney damage should also be done.

The information contained above is not intended nor implied to be a substitute for professional medical advice, it is provided for educational purposes only for general public. You assume full responsibility for how you choose to use this information.

Next month, we will talk about medical management of diabetes.

Odessa, TX

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