Initial assessment:

A full history is needed

risk factors of cardiovascular diseases, such as
smoking, hypertension, obesity, hyperlipidaemia
and family history.
symptoms of cardiovascular complications
including angina, heart failure and claudication
visual symptoms
symptoms of neuropathic complications such as
numbness, pain, muscle weakness, gastrointestinal
symptoms including diarrhea, impotence and
bladder dysfunction
drug history
past history
gestational history.
A complete examination:

Certain aspects of the physical examination

should receive special attention. These include:
height and weight measurements
blood pressure (lying and standing positions
to detect postural change)
cardiovascular examination for abnormal signs
and assessment of peripheral pulses
examination of the lower limbs for peripheral
pulses, sensation, ankle jerk and foot
lesions
ophthalmoscopy with dilated pupils.
Laboratory assessment should include:
blood glucose measurement as a minimum
requirement to confirm the diagnosis
urine examination for ketones, protein and
glucose
serum creatinine measurement in all
hypertensive patients and those with
proteinuria
electrocardiography and measurement of total
serum cholesterol and triglycerides in high-
risk individuals
Short-term Goals of Therapy :
Establish and maintain optimum glycemic
control.
More than 50% of self-monitored blood
glucose (SMBG) within target range
The therapeutic plan for Type 1 diabetes
involves:
a specific goal in the management of IDDM in
children is to ensure normal growth and
development of the child.
Long-term Goals of Therapy:

Normal growth and development

Reduce risk for microvascular (retinopathy,
neuropathy, and nephropathy) and
macrovascular complications (coronary heart
disease, stroke, and peripheral vascular
disease)
Reduce mortality
 Treatment for Type 1 Diabetes
Insulin Therapy:

Insulin is the only medication that is effective in

lowering blood glucose levels in type 1
diabetes.
use of insulin requires daily management of
those factors that affect the insulin dose.
Rapid-acting insulin may begiven before,
during, or immediately after a meal.
Administration after a meal may help reduce
the postprandial hyperglycemia associated
with high fat meals.
 Conventional therapy 2 daily injections of mixed
insulin (rapid- or short-acting and intermediate-
acting) before breakfast and the evening meal.
Conventional therapy with a split night-time dose
1 injection of mixed insulin (rapid- or shortacting
and intermediate-acting) before breakfast, 1
injection of rapid- or short-acting insulin before
the evening meal and 1 injection of intermediate-
acting insulin before the bedtime snack.
This regimen is used to help reduce fasting
hyperglycemia associated with the long interval
between the evening meal and breakfast and the
duration of action of the intermediate-acting insulin
and to facilitate management of the dawn
phenomenon.
 The insulin dose depends on basal needs, food
intake (especially the total amount of
carbohydrate) and amount of physical activity.
Changes in the dose of rapid- or short-acting
insulin can be made.
The goals of MNT that apply to specific situations
include the following:

For youth with type 1 diabetes, to provide adequate energy

to ensure normal growth and development, and to integrate
insulin regimens into usual eating and physical activity habit

For older adults, to provide for the nutritional and

psychosocial needs of an aging individual For individuals
being treated with insulin or insulin secretagogues, to
provide self-management education for treatment of
hypoglycemia, acute illnesses, and exercise-related blood
glucose problems
For individuals at risk for diabetes, to decrease the risk by
encouraging physical activity and promoting food choices
that facilitate moderate weight loss or at least prevent weight
gain
Medical Nutrition Therapy:

Food intake influences the amount of insulin

required to meet blood glucose target goals.
Dietary.
carbohydrate influences postprandial blood
glucose levels the most and is the major
determinant of meal-related insulin
requirements. The intermediate- or longer-
acting insulin usually covers the effects of
protein and fat.
Calorie:
To maintain desirable rate of growth, energy
allowance of children 1 to 9 is 90 Kcal per
kilogram desirable body weight /day and
children from 10 to 19 years 55 Kcal
Protein:
1.3 gm / kg desirable body weight for children
1-9 years is 90 kcal desirable body weight /day
and 1.8 gm/ kg for 10-19 years.
Exercise:
o Regular exercise is important to promote well-
being and reduce vascular complication.
o Exercise may rapidly reduce blood glucose level,
particularly when it coincides with the peak action
of an insulin injection .

Type 1 DM are prone to either hyperglycemia or

hypoglycemia during exercise, depending on
the preexercise plasma glucose, the circulating
insulin level, and the level of exercise-induced
catecholamines. If the insulin level is too low, the
rise in catecholamines may increase the plasma
glucose excessively, promote ketone body
formation, and possibly lead to ketoacidosis.
 ifthe circulating insulin level is excessive, this
hyperinsulinemia may reduce hepatic glucose
production and increase glucose entry into
muscle, leading to hypoglycemia.
To avoid exercise-related hyper- or
hypoglycemia, individuals with type 1 DM
should:
(1) monitor blood glucose before, during, and
after exercise.
(2) delay exercise if blood glucose is 14
mmol/L (250 mg/dL)
(3) Monitor glucose during exercise and ingest
carbohydrate to prevent hypoglycemia
(4) decrease insulin doses (based on previous
experience) before exercise and inject insulin
into a nonexercising area
(5) learn individual glucose responses to
different types of exercise and increase food
intake for up to 24 h after exercise, depending
on intensity and duration of exercise.
Self-monitoring of blood glucose (SMBG)
SMBG is an integral component of diabetes
therapy.
Patient uses a glucose monitor and a small
blood sample, usually a finger prick, to
measure the amount of glucose in the blood.
SMBG should be performed at least 4
times/day at defined times throughout the day
(fasting, pre-meal, 2 hours post-meal, bedtime )
to ensure that blood glucose levels are
responding to the treatment regimen.
Hemoglobin A1C (HbA1C or A1C)HbA1C is a
lab measurement that measures the
percentage of glycoslyated hemoglobin in the
blood.
It is the gold standard for following long-
term glycemic control from the previous 3
months.
Medical Nutritional Therapy
Helps patients achieve goals through a food and
activity plan.
Therapeutic plan for Type 2 Diabetes
Therapeutic plan for Type 2 Diabetes
Non- pharmacologic measures:

Diet and exercise are the only therapeutic intervention

required to restore metabolic control.

Diet:
Reducing caloric intake is the primary
mechanism for weight loss, although increasing
energy expenditure by becoming more
physically active is necessary for maintaining
weight loss.
Lifestyle Modification s for patients with
diabetes:

I. Diet prescription
1. weight reduction
2. carbohydrate: 40-65%
3.Restriction of the saturated fats
4. Increase monosaturated fats
5. Decrease cholesterol intake <200mg/d
6. Sodium restriction in patient prone to
hypertension
 Calculate the Desirable Body Weight
(DBW)
Determine appropriate Total Energy
Allowance (TEA) per day
Distribution of energy allowance into
Carbohydrate, Protein and Fat
 Estimation of Desirable Body Weight
(DBW)
1. HAMWI Method
Male = 105 lbs for the 1st 5 ft of height plus
5 lbs per inch for each inch above 5 ft
Female = 100 lbs for the 1st 5 ft of height plus
5 lbs per inch above 5 ft
 Estimation of Desirable Body Weight (DBW)
2. NDAP Method
Male - 5 feet = 112 lbs (add 4 lbs for every inch
over 5 ft.)
Female 5 ft = 106 lbs (add 4 lbs for every inch
over 5 ft.)
 Determination of the Total Energy Allowance (TEA)
- multiply DBW with the corresponding values according to
the following activities

ACTIVITY Kcal/kg DBW/day

Bed rest but mobile 27.5
(hospital patients)
Sedentary (most sitting 30.0
typist, bank teller, cashier,
administrators)
Light (office workers, most 35.0
professionals- lawyers,
doctors,nurses,
accountants)
 ACTIVITY Kcal/kg DBW/day

Moderate (students, painters, 40.0

heavy work, housewife w/o
maid, vendors)
Very active (unskilled laborers, 45.0
forestry workers, soldiers on
active service, mine workers,
fishermen, dancers, athletes,
steel workers)
 Distribution of Total Energy Allowance into CHO,
CHON, Fat
1. Percentage of CHO, CHON, Fat Distribution
CHO - 55-70% TEA
CHON- 10-20% TEA
FAT - 20-30% TEA
Ex. 1500 Calories (60% CHO, 15% CHON, 25% Fat)
CHO 1500 x 0.60 = 900 calories
CHON1500 x 0.15 = 225 calories
Fat 1500 x 0.25 = 375 calories
 Distribution of Total Energy Allowance into CHO,
CHON, Fat
2. Calculate the number of grams of CHO, CHON and
Fats by dividing the calories for each nutrient by the
corresponding physiologic fuel values:
4 kcal/g CHO
4 kcal/g CHON
9 kcal/g FAT
Ex. CHO = 900/4 = 226 g
CHON = 225/4 = 56.2 or 55 g
FAT = 375/9 = 41.7 or 40 g
 Distribution
of Total Energy Allowance into
CHO, CHON, Fat

DIETARY PRESCRIPTION:
1,500 kcal
CHO 225 g
CHON 55 g
FAT 40 g
 Healthful food choices:
Foods containing carbohydrates
whole grains, fruits, vegetables and low-fat dairy
Sucrose (e.g., table sugar) and sucrose-containing
foods do not need to be restricted

Reduce total caloric intake by moderation

food/beverage and limiting total fat intake.
Because carbohydrate has the greatest impact on
blood glucose, its effect can be minimized by the
distribution of carbohydrate as evenly as possible
throughout the day to smaller meals and snacks.
 limit
alcohol intake to one drink per day for
women and two drinks per day for men
To reduce the risk of hypoglycemia, alcohol should be
consumed with food.
In insulin-resistant individuals, reduced energy
intake and modest weight loss improve
insulinresistance and glycemia in the short
term.
Avoid protein intakes of greater than 20% of
total daily energy.
A balanced meal plan for a diabetic should include a
complex carbohydrate source from high fiber
grains that is low in glycemic index
good source of protein from lean meats, as well as fruit
and vegetables.
Since diabetics are two to four times more likely to
develop heart disease than people without the disease,
a good meal plan should be one that not only controls
blood sugar but should likewise help reduce the risk
for heart disease.
It should therefore be low in saturated fat and
cholesterol as well as low in salt.
Calories
Caloric goals should be those that help the
patient reach and maintain ideal body weight.
Weight-maintaining diets for moderately active
individuals include 30-35 kcal/kg/day.
For purposes of weight reduction, obese
patients can have their intake moderately
reduced by 5-15 kcal/kg/day (i.e., down to 20-
30 kcal/kg/day), particularly if they are
sedentary.
If usualcaloric intake is reduced by 500
calories/day, gradual weight loss of 1 lb per
week should occur.
Asymptomatic cardiovascular disease appears at
a younger age in both type 1 and type 2 DM,
formal exercise tolerance testing may be
warranted in diabetic individuals with any of
the following:
Age 35 years, diabetes duration 15 years (type
1 DM) or10 years (type 2 DM), microvascular
complications of DM (retinopathy,
microalbuminuria, or nephropathy), peripheral
arterial disease, other risk factors of coronary
artery disease, or autonomic neuropathy
Type of Exercises for Diabetic Patients

Thebest form of exercise recommended to a

diabetic is a step wise increase of aerobic
exercises. Plain brisk walking is the simplest
and safest of all exercises. It can be started by
any one. All the aerobic like badminton, tennis
and basket ball improve the cardio-respiratory
functions and utilize a large portion of muscle
mass. On the other hand weight lifting,
sustained and grip are to be avoided in
diabetics as they increase the arterial pressure
and/ or precipitable angina.
II.Exercise:
Regular exercise is a useful treatment of diabetes. It can
improve insulin action and weight loss.
facilitating control of hypertension and improving
dyslipedemia.

The Exercise Prescription:

Frequency:
35 times per week (increasing to most days of the
week)
Intensity:
Moderate intensity: 5570% of age predicted maximal
heart rate, or perceived exertion of 35 on a scale of 0
(easiest) to 10 (hardest) effort, or 3 miles/hour.
Time:
3045 minutes (shorter, more frequent bouts in
individuals who have been inactive; increase to 60
minutes per day)
There are several potential risks of exercise for
patients with diabetes:
Careful screening for underlying cardiac
disease is important in all patients with
diabetes before starting any exercise.
Exercise may aggravate several complications
of diabetes and hence all patients should be
screened thoroughly before initiating exercise.
Patients with proliferative retinopathy may
develop vitreous hemorrhages. Heavy weight
lifting and Valsalva maneuver are particularly
dangerous.
Treatment strategies:
Monitoring:
Self- monitoring of blood glucose level.
Glycohemoglobin:
Providing an index of glycemic control during the
peceding 6-12 weeks.
Medical nutritional therapy:
To facilitate changes in eating and physical activity
habits that reduce insulin resistance and improve
metabolic status .