Abc do diabetes

Abc do diabetes

(Parte 7 de 19)

The actual requirement for carbohydrate varies considerably; it is unsatisfactory to recommend less than 100g daily, and control may become more difficult if more than 250g daily is allowed. The smaller amounts are more suitable for elderly, sedentary patients while the larger amounts are more appropriate for younger, very active people particularly athletes who may need considerably more. Although it has been observed that not all carbohydrate-containing foodstuffs are equally absorbed and that they do not have the same influence on blood glucose values, it is impracticable to make allowances for such variations other than recommending that sugar (sucrose) should be avoided except for the treatment of hypoglycaemia.

For social convenience it is customary to advise that most of carbohydrate should be taken at the main meals—breakfast, lunch, and dinner—even though these are not necessarily the times when, according to blood glucose profiles, most carbohydrate is needed; for example, less carbohydrate at breakfast and more at mid-morning and lunch often improves the profile. Snacks should be taken between meals—that is, at elevenses, during the afternoon, and at bedtime—to prevent hypoglycaemia. At least the morning and night snacks are essential and should never be missed.

For the convenience of some, and for those adopting the

DAFNE method of controlling Type I diabetes and therefore needing to calculate the carbohydrate content of their meals, 10g of carbohydrate is described as “one portion” so that a 170g carbohydrate diet is described to patients as one of “17 portions”. Patients sometimes find it valuable to know the carbohydrate values of different foodstuffs.

Foods suitable during intercurrent illness The presence of malaise, nausea, and anorexia during illness may deter patients from eating, yet food is needed to avoid hypoglycaemia following insulin administration, which should never be stopped (see page 37). Suitable foodstuffs for use at this time are shown in the box.

Weight control: the role of exercise Weight control towards optimal levels yields considerable health benefits to all, notably in this context to those who have the combined disadvantages of being overweight and having Type 2 diabetes. Exercise has a central role in weight reduction and health improvement. The proven benefits include reduced insulin resistance (hence enhanced insulin sensitivity) leading to better glycaemic control which may even be independent of actual weight reduction. Risk factors for cardiovascular disease,

A sample meal plan for a Type 1 diabetic

Carbohydrate Recommended food portionsand drink

Breakfast 1 Fruit 1Wholemeal cereal 1 Milk

1Wholemeal bread

Egg/grilled bacon Tea/coffee

Mid-morning 1 Fruit/plain biscuit Tea/coffee/diet drink

Lunch Lean meat/fish/ egg/cheese

2 Potatoes/bread/rice/ pasta

Vegetable salad 2 Fruit/sugar-free pudding

Mid-afternoon 1 Fruit/plain biscuit Tea/coffee/diet drink

DinnerLean meat/fish/eggs/ cheese

2 Potatoes/bread/rice/ pasta

Vegetable salad 2 Fruit/sugar-free pudding

Bed-time 1 Bread/fruit/plain biscuit

Tea/coffee/diet drink Total 15

Alcohol

•Alcohols containing simple sugar should not be drunk by people with diabetes, especially sweet wines and liqueurs

•Dry wines and spirits are mainly sugar-free and do not present special problems

•Beers and lagers have a relatively high sugar and calorie content and their amount needs to be both limited and counted as part of the controlled carbohydrate intake

•Sugar-free beers are high in calorie and alcohol content and therefore have some limitations to their usefulness, whereas “low alcohol” beers are high in carbohydrate

•Profound hypoglycaemia may be provoked in those who take large amounts of alcohol, and omit their normal diet, especially in those taking sulphonylureas; this can be dangerous

•Normal social drinking is usually free from this hazard but care is still needed

•Reduction in alcohol intake is sometimes an important part of helping weight loss

Aims of treatment: a healthy lifestyle which include high blood pressure, also diminish. Indeed, the prevention of Type 2 diabetes itself in those at high risk has been amply demonstrated (see page 6). People with osteoarthritis, chronic heart failure, and chronic lung disease all benefit from appropriate exercise programmes and weight reduction, and there are advantages to those recovering from myocardial infarction. A healthier life is also gained by the very old and by the overweight child. For those with Type 2 diabetes it is recommended that exercise of moderate intensity should be undertaken for about 30 minutes each day. This can include walking, as well as both aerobic and resistance exercise.

The effects of exercise in Type 1 diabetes present the hazard of hypoglycaemia and it is not a specific contributor to improvement of diabetes control. Advice is required on the use of insulin and the need for additional food (in particular carbohydrate) before, during, and after periods of exercise especially (since hypoglycaemia may develop after cessation of exercise) for those engaged in major sports and athletics. The challenge for sportsmen can be extreme but nevertheless people with Type 1 diabetes are known for huge achievements. Great credit went to Sir Steven Redgrave for his ingenious food and insulin regimen which enabled him to win a rowing gold medal in the 2000 Olympic Games.

Smoking The addiction of smoking is now well established. Its harmful effects are numerous, and include a substantial increase in cardiovascular and peripheral vascular disease as well as the best known consequences of lung cancer and chronic obstructive pulmonary disease. In diabetes, higher rates of both nephropathy and retinopathy have been well documented.

Nicotine replacement therapy using proprietary sublingual preparations, chewing gum, self adhesive patches, or alternatively amfebutamone tablets can help, especially if used in conjunction with the counselling which is provided by smoking clinics. Detailed use of these medications is described in the British National Formulary(BNF).

How 10 fat men and 10 lean men fare on the journey through life (Joslin, 1941)

The story of Mrs B-J continued: the diet

I was put in a Women’s ward and I was given my first dose of insulin. The bed was in the centre of the ward and I soon became the ladies’ pet. They threw sweets on to my bed, which I politely refused, no doubt recalling how I had forsworn such poison.

I stayed in hospital for three weeks, and each day I was given lessons in diet. I had a red exercise book in which I set out different diets, stating the weight and value of each carbohydrate item. I had a chart with various foods listed. Those printed in black were called “black lines” and had to be limited by weight to equal the “black lines” allowed at each meal. The protein foods were “red lines” and could be taken ad lib.

The histogram of risk reduction for complication in young Type 1 diabetic patients under intensive diabetic control is adapted from Watkins PJ, et al. Diabetes and its management, 5th ed. Oxford: Blackwell Science, 1996. The histogram showing prevalence of obesity in England is adapted from Nutrition and Obesity Task Force. Obesity: reversing the increasing problems of obesity in England. London: Department of Health, 1995. The illustration of how 10 fat men and lean men fare through life is from Joslin EP. Diabetic manual, 1941, Lea and Febiger.

Type 2 diabetes is a complex disorder generally affecting older people who are often overweight and likely to suffer other medical problems as well. Its management presents considerable challenges to medical and nursing staff, whose care must be directed at the sum of the problems of the individual patient. Management now requires not only attention to blood glucose control, but also to the treatment of hypertension and hyperlipidaemia, as well as introducing the necessary measures for reducing cardiovascular risk factors.

Optimal treatment of Type 2 diabetic patients, especially those who are symptom-free, overweight and have in addition several cardiovascular risk factors, exercises our clinical skills and judgments to the limit. There needs to be a sense of reality within the consultation, bearing in mind the potential dangers of unacceptable polypharmacy accompanied by low adherence to prescribed treatment as well as a sense of guilt experienced by those who fail to achieve ideal targets set by physicians. Awareness of the priorities and intentions of individual patients needs to be given consideration, and patients need to agree on the objectives for treatment. Recommendations for treatment must be clinically relevant for the individual patient, who should be involved in choosing which of the many therapeutic options to select after explanation of advantages and risks. The difficulties of controlling Type 2 diabetes tend to increase with the passage oftime as the disease progresses. Management is often difficult and needs to be pragmatic: the late Professor John Malins when asked how this should be done used to quote the advice given by Chekhov to his actors—that it should be “done as well as possible”.

Glycaemic control

Natural history Type 2 diabetes is an insidiously progressive disease. Gradually decreasing insulin secretion leads to a slow increase in hyperglycaemia and a rise of HbA1cvalues, often despite vigorous clinical attempts to maintain control. Thus, while control during the early years is often straightforward, it becomes increasingly difficult with the passage of time, so that the appropriate need for tablets and insulin requires continuing consideration.

Non-obese patients Such patients require different consideration from the obese. They are much more likely to require insulin early in the course of treatment, and indeed apparent presentation as Type 2 diabetes may be deceptive when they progress to Type 1 diabetes as cases of latent autoimmune diabetes of adulthood (LADA). Sulphonylurea treatment is used initially while metformin treatment is inappropriate for these patients. Some of them cling desperately to minute diets with the large doses of sulphonylureas as weight and health decline: these patients regain their health rapidly when insulin treatment is started and indeed it should not be delayed.

Obese patients These patients require a different approach. The need for healthy eating and exercise in an attempt to reduce weight are paramount yet difficult to achieve. When these measures fail,

4Treatment of Type 2 diabetes mellitus

Progression of diseaseTreatment

Obesity Insulin resistance

Decreasing insulinsecretionHyperinsulinaemia

MetforminInsulin sensitisers Insulin secretagogues(For example, sulphonylureas)DietExercise Insulin

Natural history of Type 2 diabetes

(Parte 7 de 19)

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