OS 214: Gastroenterology NIM module

Nutrition and Diabetes Final Exam

• carbohydrate diets induce prolonged increase in

Lecture Outline: blood glucose
I. Diabetes: Nutritional Mechanisms • glucose uptake is not sufficient to balance high
A. Breakdown of Dietary Carbohydrates glucose in the blood
B. Metabolism of Glucose • in patients with DM, small frequent feeding is
C. Diabetes mellitus advised
D. Hormonal Regulation of Blood Glucose
E. Obesity and Type2 Diabetes
D. Hormonal Regulation of Blood Glucose
F. Gestational Diabetes mellitus
II. Diabetes: Dietary Management 1. Insulin: a polypeptide hormone from beta cells of
A. Energy Balance Islets of Langerhans
B. Glycemic Response - Actions of Insulin
C. Medical nutrition Therapy Increases Decreases
D. Myth vs. Fact Glucose uptake Gluconeogenesis
E. Glucose Management Tools Amino acid uptake and Glycogenolysis
III. Diabetes: Filipino Setting protein synthesis
A. Filipino Profile
B. Filipno Diet Guidelines
Fatty acid synthesis Lipolysis
IV. Appendix Glycogenesis proteolsysis
Glycolysis
I. Diabetes: Nutritional Mechanisms
A. Breakdown of Dietary Carbohydrates  overall DECREASE in blood glucose
- Carbohydrates: molecules made up of carbonm,
hydrogen and oxygen Insulin-Stimulated Glucose Uptake
Compound Description Examples Insulin binds to tyrosine kinase receptors 
translocation of GLUT4 (glucose transporters to cell
Monosaccharides Composed of one Glucose,
sugar unit fructose, membrane  increased glucose uptake by the cell
mannose,
galactose Insulin Secretion
Dissacharides Composed of Two Maltose, Stimulators:
sugar units lactose, a. post-prandial surge of glucose, amino acids and
sucrose fatty acids
b, incretin hormones
Polysaccharides Composed of long starch
c. acetylcholine
chains, usually >10
Repressors:
units
a. leptin
- Processing
b. sympathetic nervous system (eg, norepinephrine)
1. Digestion
• amylase from the salivary glands and pancreas
2. Chromium: part of a complex that enhances
acting on sugar molecules
insulin receptor activity (thus, improves glucose
• end products: glucose and maltose
uptake by the cell)
2. Absorption and Transport
• simples sugars (monosaccharides and • adequate intake is 35 ug/day for men; 25 ug/day
pentoses) are absorbed in the duodenum and for women
jejunum • souces: processed meat, broccoli, raw onions,
• process is energy-dependent (active transport) whole grain
through carrier proteins • deficiencies are rare, but excess amounts do not
• glucose is brought to the liver via the portal vein have any beneficial effect
at the rate of 1g glucose/kg b.w./hour
• glucose goes through the glycolytic pathway 3. Glucagon: polypeptide hormone from alpha cells
(fructose and galactose also ulitize this of Islets of Langerhans
pathway), to produce energy, or is stored as Increases Decreases
glycogen Gluconeogenesis Glycogenesis
3. Metabolism Glycogenolysis Glycolysis
• monosaccharides are phosphorylated, then Lipolysis Synthesis of glycolytic
metabolized via glycolysis, petose-phosphate enzymes
pathway (PPP), or is stored as glycogen Ketgenesis
• special sugars given to diabetics such as  overall INCREASE in blood glucose
sorbitol and xylitol are metabolized slowly
Glucagon Secretion
B. Pathways for Glucose Metabolism Stimulators:
1. glycolytic pathway a. Low blood glucose
2. pentose phosphate pathway b. Increased circulating amino acids
3. Kreb’s Cycles c. Sympathetic nervous system (eg, norepinephrine)
4. Gluconeogenesis Repressors:
5. Cori Cycle a. Hyperglycemia
6. Glycogenesis b. Increased circulating fatty acids
c. Somatostatin
C. Glucose Handling in Diabetes

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 OS 214: Gastroenterology NIM module
Nutrition and Diabetes Final Exam

Metabolic effects of insulin and glucagon (See • History of gestational diabetes

appendix A) • African-American, Hispanic or Native-American
ethnicity
Epinephrine and Cortisol • Hypertensive (> 140/90)
Epinephrine Cortisol • HDL ≤ 35mg/dl and/or TG ≥ 250 mg/dl
- secretes by the adrenal - produced by the
medulla in response to adrenal cortex in Obese vs. Lean Glucose Curves
acute stress (fight or response to stress,
flight response) trauma and
- increase in glycogen hypoglycemia
breakdown - works synergistically
- Increases with glucagon by
gluconeogenesis from activating key
lactate and amino acids gluconeogenic enzymes,
- increases mobilization phosphoenolpyruvate
of fat via activation of carboxykinase (PEPCK)
hormone-sensitive lipase - indirectly maintains
- metabolic effects are glucose production (from
mediated by both alpha protein) and facilitates fat
and beta receptors.. the metabolism
latter predominates in
humans Glucose Curve: Obese

Fed vs. Fasted States

Fed (post-prandial) Fasted (long term)
- insulin secretion - glucose levels fall
increases - Energy sources are
- absorbed nutrients are mobilized
utilized and stored - insulin secretion drops
- breakdown of stored to basal levels
nutrients is suppressed - Glucagon activity
increases
* even at low concentrations, insulin inhibits lipolysis

Regulation of Glycogen Stores

Insulin Glucagon
- stimulates glycogen - moblizes glycogen Glucose Curve: Lean
synthesis (glycogenesis) (glycogenolysis) by:  The glucose curve for obese individuals exhibits a
by: a. promoting higher post-prandial blood glucose level surge
a. promoting phosphorylation compared to that of the lean individual’s.
dephosphorylation (inhibition) of glycogen
(activation) of glycogen synthase F. Gestational Diabetes
synthase b. promoting • Nutritional status of the mother can affect the
b. promoting phosphorylation fetal genome
dephosphorylation (activation) of glycogen • Maternal overnutrition may restrict fetal growth
(inhibition) of glycogen phosphorylase (via impaired placental development) and
phosphorylase increase the risk of neonatal mortality and
morbidity
Integrated Regulation of Metabolism (see appendix • Gestational diabetes mellitus (GDM), a
B) condition associated with maternal overnutrition
and defined as any degree of glucose
E. Obesity and Type 2 Diabetes intolerance
Obesity as a Risk Factor for DM • Hormones released from the placenta interfere
• Muscle and adipose tissue lose responsiveness with maternal responsiveness to insulin
to insulin with excess gain weight
• Delayed blood glucose clearance after a meal QUICK OB-ENDO REVIEW!
• Increased hepatic glucose production Characteristics associated with a LOW risk of GDM
• Increased insulin production = pancreas failure <25 years old
• Individuals at risk should be routinely tested Normal pre-pregnancy weight
Ethnicity associated with a low prevalence of GDM
Individuals at Risk No first-degree relatives with DM
• BMI ≥ 25 No history of abnormal glucose tolerance
• First degree relative with diabetes No history of poor obstetric outcome
• Given birth to a baby > 9lbs. (4 kg)
• Impaired glucose tolerance/ elevated fasting Characteristics associated with a HIGH risk of GDM
glucose Marked obesity
Personal history of GDM
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 OS 214: Gastroenterology
Nutrition and Diabetes
Glycosuria
Strong family history of diabetes
Nutritional Counseling for Gestational Diabetes
• All women with GDM should receive nutritional
counseling from a physician or a registered
dietician
• Restricting carbohydrate intake to 35-40% of
total caloric intake (30-45 g per meal)
• Reduce hyperglycemia
• Improve maternal and fetal outcomes
• Distribute carbohydrate intake throughout the
day in three small-to-moderate sized meals and
2-4 snacks , including an evening snack
Role of exercise in GDM
• Muscle contractions activate glucose transport
independently of insulin
• Insulin sensitivity increases  more insulin-
sensitive glucose transporters (GLUT4) move to
the plasma membrane
• Increased glucose uptake  lowers blood
glucose  signals an increase in glucagon
secretion
• Exercise also triggers catecholamine release
• Glucagon and catecholamines stimulate an
increase in the hepatic glucose production and
an increase in adipose tissue lipolysis
Insulin Therapy in GDM
• If diet and exercise alone cannot control blood
glucose, or if the fetus becomes abnormally
large because of elevated blood glucose
• Recommended when nutrition therapy fails to
maintain self-monitored glucose at the ff. levels
a. Fasting plasma glucose </= 105mg/dL (5.8
mmol/L)
OR
b. 1hr post-prandial plasma glucose </= 155 mg/dL
(8.6mmol/L)
OR
c. 2-hr postprandial plasma glucose </= 130 mg/dL
(7.2 mmol/L)
II. Diabetes and Dietary Management
A. Energy Balance
• Energy balance: energy intake matches energy
requirements
• In healthy individuals, energy balance = glucose
homeostasis
• Overweight, insulin-resistant individuals will
benefit from a negative energy balance; lower
blood glucose levels by inadequate caloric
intake, and improve glucose uptake by
increasing physical activity
• Chronic excessive caloric intake raises insulin
levels, promotes weight gain, and leads to
insulin resistance.
B. Glycemic Response
• After meals – glucose rises followed by an
increase in insulin levels
• Insulin – promotes glucose uptake and
utilization. As a result, glucose levels decrease.
• Protein – raises insulin secretion
November 14, 2008| FRIDAY
NIM module
Final Exam
• Fats – raises insulin secretion and delays
digestion and absorption of dietary
carbohydrates
• Normal FBS:70-90 mg/dL
Normal Post-prandial blood glucose: >140 mg/dL
Glycemic Index
• predicts the effect of carbohydrate-containing
food on postprandial glycemia
• does not account for the variability of the test
food and considers food item in isolation
• high glycemic index foods: bread, pasta, rice,
cereal, baked goods
• low glycemic index foods: fruits, vegetables,
whole grains, legumes
Hyperglycemia
• defined as FBS >/= 126 mg/dL and may be
caused by recent food intake, insufficient insulin,
stress, medications ie steroids, obesity
• potential acute consequences: ketoacidosis,
hyperosmolar non-ketotic syndrome
Symptoms:
• Hyperosmolar effects of high blood glucose
concentration result in polydipsia, polyuria,
nocturia, blurred vision, sudden unexplained
weight loss, headache
• Impaired glucose transport into cells results in:
polyphagia, sudden unexplained weight loss,
poor wound healing, chronic/recurrent skin
infections, weakness/tiredness, confusion
Intensive management
• Determining blood glucose at least 4x a day
• Using an insulin pump, or receiving an insulin
injection 4x a day
• Adjusting insulin doses according to food intake
and exercise
• Implementing a diet and exercise plan
• Seeing members of a health care team monthly
Hypoglycemia
• may occur due to: inadequate food intake,
excessive medications ie, hypoglycemic agents,
inappropriate timing of medications and meals,
excessive exercise or sudden increase in
physical activity
Symptoms:
• Early Adrenergic Response: sweating,
headache, blurry vision, hunger, weakness, poor
coordination, numbness/tingling of mouth and
lips
• Late Neurogenic Response: dizziness,
confusion, irritability/personality change,
shakiness, loss of consciousness, seizures
Treatment:
• give a source of simple carbohydrates (4oz.
orange juice or 6oz regular soft drink or 10-20g
table sugar)
C. Medical Nutrition Therapy
Goals of Medical Nutrition Therapy
• Achieving near normal blood glucose and blood
pressure levels
• Improving lipid profile
• Modifying nutrient intake and lifestyle to delay or
prevent the chronic complication of diabetes
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 OS 214: Gastroenterology NIM module
Nutrition and Diabetes Final Exam

• Addressing the nutritional needs of an individual developing diabetes

with special consideration given to personal and People with type 1 This practice would
cultural preferences and willingness to change diabetes can eat as eventually lead to weight
• Maximizing the enjoyment of food by limiting much carbohydrates as gain then increased fat
food only when indicated by scientific evidence they like as long as they deposition; poor patient
(see appendix C) compensate with enough compliance, irregular
insulin eating pattern, and
Guidelines for Macronutrient Distribution erratic blood glucose
(see appendix D) control
Individuals with Type 2 Losing 4.5 to 9g (10-
Determining Carbohydrate Requirements diabetes must reach an 20lbs) often improves
• BMI = weight in kilos / height in m2 ideal weight before their blood glucose control
• if patient is overweight, seta goal for weight loss diabetes comes under and reduce lipid levels
at 10% of body weight or BMI<25 control and blood pressure
• obtain patient’s food history and activity data
(24hrs): determine the approximate daily caloric E. Glucose Management Tools (see appendix E)
intake and physical activity (PA) level
• determine estimated energy requirement (EER) Targets for Metabolic Control: Recommendations for
[PA: 1=sedentary, 1.12=low active, 1.27=active, Adults with Diabetes
1.45=very active) a. Plasma Glucose
• males: 662 – (9.53*age in years) + Fasting 90-130mg/dl(5.0-7.2mmol/L)
PA*(15.91*weight in kg + 539.6*height in Random <180 mg/dl (<10mmol/L)
meters) b. HbA1c <7%
• females: 354 – (6.91*age in years) + • primary target for achieving glycemic control
PA*(9.36*weight in kg + 726*height in meters) • Indicates level of glycemic control over the last
• calculate suitable carbohydrate intake per day 2-3 months, assesses treatment efficacy,
and per meal measures accuracy of self-reported results
c. Plasma Lipids
D. Myths vs. Facts HDL >40mg/dl for men; >50 for women
MYTH FACT LDL <100mg/dl(2.6mmol/L)
Honey is better for Honey has more calories d. Triglycerides <150 mg/dl (1.7 mmol/L)
diabetes management than sugar; main
than sugar components are sucrose Medications
and fructose which will Types of Insulin (see appendix F)
eventually be broken
down into glucose, too Oral Hypoglycemic Agents
Individuals with diabetes All sugars are basically Agent Target Action
can have as much fruit the same…excessive Organ
and fruit juice as they fructose intake can amylin mimetics pancreas inhibit glucagon
want because these elevate serum HDL release
items contains “natural sulfonylureas pancreas stimulate insulin
sugars: components are secretion
fructose, sucrose and meglitinides Pancreas
glucose GLP-1 Agonists pancreas stimulate insulin
secretion; inhibit
Individuals with diabetes Fruit and fruit juice glucagon release
should limit their fruit contains many vitamins DPP-4 inhibitors Pancreas inhibit GLP-1
intake and avoid drinking and minerals and fiber (via GLP-1 breakdown
fruit juice but add little or no fat to agonists)
the diet; as long as the alpha- GIT delay digestion
carbohydrate remains in Glucosidase of carbohydrates
the acceptable range, inhibitors
fruit and fruit juices
thiazolidinedione muscle increase insulin
should be included in the
s sensitivity
diet.
biguanides Muscle and increase insulin
A person with diabetes A small amount of
liver sensitivity;
should only drink “diet” regular soda can be
reduce hepatic
soda incorporated into a well-
glucose
balanced diet; regular
production
soda can be a
convenient way to treat
Physical Activity
episodes of mild
• During exercise, muscle contractions activity
hyperglycemia
glucose transport independently of insulin.
You can get diabetes High intake of sugar will
Afterwards, insulin sensitivity increases.
from eating too much not lead to diabetes;
• Increased glucose uptake lowers blood glucose,
sugar however, obesity
which signals an increase in glucagon secretion.
increases the risk of

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 OS 214: Gastroenterology
Nutrition and Diabetes
Exercise also triggers the release of
catecholacmines.
• Glucagon and catecholamines stimulate an
increase in hepatic glucose production and an
increase in adipose tissue lipolysis.
• Recommend a minimum of 20-30 minutes of
moderate activity each day (approx. 150kcal).
The eventual goal is to burn about 200-300 kcal
per day to improve overall health and well-being.
III. Diabetes in the Philippine Setting
A. Filipino profile
• revels in rice, has sweet tooth, likes to order
“Meal A, with extra fries, go large”, remote
control lifestyle, masters of manyana
• therefore, Filipinos are at high risk for diabetes!
• “MANILA, Philippines—One out of every five
adult Filipinos are diabetic, according to the
latest national survey conducted on the
prevalence of diabetes in the country. The
survey, conducted in 2007 by the Philippine
Cardiovascular Outcome Study on Diabetes
Mellitus (PhilCOS-DM), further shows that as
many as three out of five adults are already
diabetic or on the verge of developing diabetes
unless they change their lifestyle.” -- Diabetes
rising among Filipinos; by Dona Pazzibugan,
Philippine Daily Inquirer, 11/11/2008
B. Filipino Diet Guidelines
Fat
• Bawasan ang pagkain ng taba o mga
matatabang pagkain.
• Bawasan ang paggamit ng taba sa pagluluto at
paghuhorno.
• Gumamit ng cooking spray sa halip ng cooking
oil.
• Kumain ng mas kaunting saturated fat. Ito ay
kadalasang nasa mga karne o animal products,
tulad ng tocino, longganiza, at sitsaron.
• Bawasan ang pagkain ng mga produktong may
halong gata, tulad ng ginatan, suman, bibingka
at biko.
• Ihawin ang isda (bangus, tilapia) sa halip na
iprito sa mantika.
• Sa pagluluto, gumamit ng mga mantika, tulad ng
canola, olive at peanut.
Sweets
• Umiwas sa softdrinks. Mas madalas piliin ang
tubig bilang inumin.
• Bawasan ang pagkain ng mga matatamis na
gawa sa gata at asukal.
• Kumain ng mas maraming sariwang prutas
bilang matamis.
Alcohol
• Kapag nais mong uminom ng alak (wine,
cervesa, whiskey, atbp.), uminom lamang ng
kaunti at isabay ito sa pagkain.
• Makipag-ugnayan sa propesyonal na
tagapangalaga ng iyong kalusugan ukol sa ligtas
na dami ng alak para sa iyo.
Milk
• Piliin ang mga nonfat o mababang taba na mga
produkto, tulad ng fat-free o mababang taba na
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NIM module
Final Exam
gatas , plain o artificially sweetened na non-fat o
mababang taba na yogurt, at mababang taba na
keso. Subukan ang nonfat dry milk o evaporated
skim milk.
• Gumamit ng non-fat dry milk o evaporated skim
milk sa kape o mga matatamis tulad ng halo-
halo o palamig (ginayat o kinudkod na mga
sariwang prutas na may halong gatas).
Meat
• Kadalasang magluto ng mga mababang taba na
mga ulam tulad ng paksiw, ihaw, tinola o
sinigang.
• Magluto ng mga karneng ulam (dinuguan,
menudo, kari-kari, batchoy) nang walang mga
laman-loob, tulad ng atay, tripe at dila.
• Bawasan ang paggamit ng mga masyadong
matabang karne, tulad ng pork liempo,sitsaron,
at chorizo o longganiza.
• Piliin ang mga beans at peas na walang dagdag
na taba sa halip ng karne, makailang beses sa
isang linggo. Ang mga ito ay mababang taba at
maiinam na kapalit ng karne, manok at isda.
Vegetables
• Maaaring kainin ang karamihan sa mga tropical
vegetables (tulad ng ampalaya, okra, bok choy,
kangkong, malunggay) kung ang mga ito ay
mabibili at hindi mahal.
• Pumili ng mas maraming orange o dark-green
na leafy vegetables, tulad ng kalabasa, spinach,
carrots at talbos ng kamote.
• Damihan ang bawang, sibuyas, sili, luya, at
lemon grass bilang pampalasa sa iyong mga
gulay. Subukang maglagay ng iba’t-ibang mga
gulay sa iyong sinigang o tinola.
Fruits
• Piliin ang mga buong prutas, pero liitan ang mga
portion. Maaari mong kainin ang karamihan sa
mga tropical fruits, tulad ng papaya, saging,
mangga, pinya at pomegranate.
• Kumain ng kahit man lamang isang prutas na
maraming vitamin C araw-araw, tulad ng orange,
grapefruit at tangerine.
• Bawasan ang pagkain ng mga fruit preserves,
tulad ng sampalok at dried mango at mga prutas
na de-lata o nasa syrup, tulad ng langka, kaong,
matamis na bao, macapuno at nata de coco.
Grains, beans, etc
• Kumain ng mga tubers tulad ng gabi, ube,
cassava at kamote, na kabilang sa mga starchy
vegetables. Ang mga root tubers ay mahusay na
kapalit sa kanin, noodles at tinapay.
• Kumain ng mas maraming mga beans bilang
fiber. Ang mga mahuhusay na halimbawa ay
munggo, garbanzos, at kadyos.
• Gumamit ng iba’t ibang mga noodles (pancit),
tulad ng bihon, sotanghon at misuwa.
• Bawasan ang serving ng kanin bawat araw
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 OS 214: Gastroenterology NIM module
Nutrition and Diabetes Final Exam

APPENDICES

Appendix A: Metabolic effects of insulin and glucagon

INSULIN GLUCAGON
PROTEIN Synthesis
Inc. transport of branched Catabolism Inc. use of alanine and other amino
chain amino acids to tissues acids from muscle protein for
Inc. ribosomnal protein gluconeogenesis
synthesis, particularly in liver
and muscle cells
CARBOHYDRATES Energy, Inc. GLUT-4 mediated Synthesis Inc. mobilization of glycogen stores
storage glucose uptake (activates glycogen phosphorylase
Inc. glycolysis (activates va increased synthesis of CAMP)
glucokinase) Inc. gluconeogenesis (activates
Inc. glycogen snthesis phosphoenolpyruvate
(increases glucose 6- carboxykinase and other enzymes)
phosphate levels, activates
glycogen synthase, inhibits
glycogen phosphorylase)
Dec. gluconeogenesis
FATS Synthesis, Inc. fatty acid synthesis and Catabolism Inc. mobilization of triglycerides
storage esterification from adipose tissue
Dec. ketogenesis Inc. keotgenesis
Dec. lipolysis (inhibits
hormone-sensitive lipase)

Appendix B: Integrated Regulation of Metabolism

BLOOD LIVER MUSCLE FAT
INSULIN Dec. blood Protein synthesis Protein synthesis Lipogenesis
glucose Glycogenesis Glycogenesis Glucose uptake
Glucose uptake Glycolysis
Glycolysis

GLUCAGON Inc. blood Gluconeogenesis Lipolysis

glucose Glycogenolysis
Ketogenesis

EPINEPHRINE Inc. blood Gluconeogenesis Glycogenolysis Lipolysis

glucose Glycogenolysis

CORTISOL Inc. blood Gluconeogenesis Protein catabolism Lipolysis

glucose

Appendix C: Goals of Medical Nutrition Therapy

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 OS 214: Gastroenterology NIM module
Nutrition and Diabetes Final Exam

Appendix D: Guidelines for Macronutrient Distribution

Dietary Reference Intake for Healthy ADA recommendations for people
Individuals with Diabetes
Carbohydrates 40-65%

Proteins 10-35% 15-20% of total calories

Fats 20-35%

Saturated Fat <7% of total calories

Cholesterol <200mg/d

Dietary Fibers 38g/day males; 25g/day females

Appendix E: Glucose Management Tools

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 OS 214: Gastroenterology NIM module
Nutrition and Diabetes Final Exam

Appendix F: Types of Insulin

Type Onset Peak Duration

Rapid Acting – injected
right before meals
Lispro 5 mins 0.5-1 hour 3 hours
Aspart 10-20 mins 1-3 hours 3-5 hours
Glulisine <15 mins 1-2 hours 3-4 hours
Short Acting – injected
30-40mins before meals
Regular 30 mins 2-5 hours 5-8 hours
Intermediate – works all
day if taken in the morning
NPH 1-2 hours 6-10 hours 10 hours
Lente 2-4 hours 8-12 hours 18-24 hours
Long-acting – usually
taken at bedtime
Ultralente 4-6 hours 10-18 hours 24-28 hours
Glargine 2-4 hours No peak 24 hours
Detemir 0.8-2 hours No peak Up to 24 hours

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