An impaired value equal to or greater

than 126 mg/dL

Symptoms of diabetes and a nonfasting
plasma glucose (casual) value of
greater than or equal to 200 mg/dL
Casual any time of the day, without regard
to the elapsed time since ones last meal
A 2-hr pp glucose equal to or greater
than 200 mg/dL during an OGT test
involving administration of 75g glucose
Diagnosis
Diabetes
Impaired glucose homeostasis
Impaired fasting glucose
Impaired glucose tolerance
Normal
Criteria
FPG 126 mg/dL (7.0 mmol/L)
CPG 200 mg/dL (11.1 mmol/L)
2hPG 200 mg/dL (11.1 mmol/L)
FPG 110 and < 126 mg/dL
2hPG 140 and < 200 mg/dL
FPG < 110 mg/L (<6.1 mmol/L)
2hPG <140 mg/dL (<7.8 mmol/L)

FPG Fasting Plasma Glucose

CPG Casual Plasma Glucose
2hPG 2-hr Plasma Glucose
 Measures blood glucose in a person who
has not eaten anything for at least 8
hours
Used to detect DM of pre-diabetes
Preferred test for diagnosing DM
because of its convenience and low
cost
Most reliable when done in the morning
Plasma Glucose Result (mg/dL) Diagnosis
<110 Normal
110; <126 Pre-diabetes (IFG)
126 Diabetes
 More sensitive than FPG test for
diagnosing pre-DM but it is less
convenient to administer
Requires fasting for at least 8 hrs before
the test
Plasma glucose level is measured
immediately before and 2 hours after a
person drinks a liquid containing 75 g of
glucose dissolved in water
2-hr Plasma Glucose Result (mg/dL) Diagnosis
139 Normal
140; <200 Pre-DM (IGT)
200 DM
 Based on plasma glucose values
measured during the OGTT
Using 100g of glucose in liquid
Blood glucose levels are checked 4x
during the test
If blood glucose levels are above N at
least 2x during the test, the woman has
GDM
 Preexisting DM Gestational DM
Test
(mg/dL) (mg/dL)
Fasting plasma 65-100 80-110
glucose
Premeal 65-110
1-hr PP <145 <155
2-hr PP <135 <130
2-6 hr PP 65-135
Normal values during pregnancy
FPG 70-105
1-2 hr PP 140
 All pts 45 yo
If normal, tests should be repeated at 3-
year intervals
Testing should be considered at a younger
age or be carried out more frequently in
patients who:
Have a family history of diabetes
Are OW with a BMI of 25 kg/m2
Are members of a high-risk ethnic population
(African Americans, Hispanic Americans, Native
Americans, Asian Americans, Pacific Islanders)
 Are women who have a hx of GDM or a hx
of having infants weighing >9 lbs (~4 kg) at
birth
Are hypertensive
Have a HDL cholesterol level 35 mg/dL or a
TG level of 250 mg/dL
Had IGT or IFG on previous testing
Have polycystic ovary syndrome

IGT Impaired Glucose Tolerance

IFG - Impaired Fasting Glucose
 Youth who are OW (BMI >85 percentile
for age and sex)
Have 2 of the following risk factors:
Family history of DM Type 2
Members of high-risk ethnic populations
Signs of insulin resistance (eg acanthosis
nigricans)
 Age 10, or
Onset of puberty

FREQUENCY:
Every 2 years
 PCOS
A common disorder that affects
premenopausal women and is
characterized by chronic anovulation
and hyperandrogenism
Insulin resistance is seen in a significant
subset of women with PCOS, and the
disorder substantially increases the risk for
type 2 DM, independent of the effects of
obesity.
 Optimum control of DM requires the
restoration of normal CHO, PRO, fat
metabolism
Insulin anabolic and catabolic
Facilitates cellular transport
Goal of treatment:
Provide the patient with the necessary tools to
achieve the best possible control of glycemia,
lipidemia, and BP to prevent, delay or arrest the
micro- and macrovascular complications of DM
while minimizing hypoglycemia and excess weight
gain
 BIOCHEMICAL INDEX NORMAL GOAL
Plasma Values
Average preprandial glucose <110 90-130
(mg/dL)
Peak postprandial average <140 <180
plasma glucose (mg/dL)
(measured within 1-2hr after
eating)
A1c (%) <6 <7
 Requirement:
Open communication
Appropriate self-management education
Patients self-assessment is possible
Day-to-day glycemic control by:
self-monitoring of blood glucose
Measurement of urine and blood ketones
 Assessed through:
Hemoglobin A1c (Hb1Ac )
When Hgb and other proteins are exposed to
glucose, the glucose becomes attached to the
protein in a slow, nonenzymaticand concentration-
dependent fasion
Measuresment reflect a weighted average of
plasma glucose concentration over the preceding
weeks
A1c values of 4-6% ~ 90 mg/dL

Lipids and BP should also be monitored

Lipids (mg/dL) Blood Pressure (mm Hg)
Cholesterol <200 Systolic <130
LDL cholesterol <100 Diastolic <80
HDL cholesterol
men >45
women >55
Triglycerides <150
 Faith.
Hihi!

Integral to total diabetes care and

management
Requirements:
Coordinated team effort (including a skilled
dietitian)
Individualized approach and effective
nutrition self-management education
 Improves glucose control
Improves lipid and lipoprotein profiles
and BP
Improving heath through food choices
and physical activity is the BASIS of all
nutrition recommendations for the
treatment and prevention of diabetes.
Goals of Medical Nutrition Therapy that Apply to All Persons with
Diabetes
1. Attain and maintain optimal metabolic outcomes including:
Blood glucose levels in the normal range or as close to normal as
is safely possible to prevent or reduce risk or complications of
diabetes.
All lipid and lipoprotein profile that reduces the risk for CVD.
BP levels that reduce the risk for vascular disease.
2. Prevent and treat the chronic complications. Modify nutrient intake
as appropriate for the prevention and treatment of obesity, CVD, HPN
and nephropathy.
3. Improve individual nutritional needs taking into consideration
personal and cultural preferences and lifestyle while respecting the
individuals needs and willingness to change.
Goals of Nutrition Therapy that Apply on Specific Situations
1. For youth with Type 1 DM, provide adequate E to ensure N gd;
integrate insulin regimen into usual eating and exercise habits.
2. For youth with Type 2 DM, facilitate changes I eating ad exercise
habits that reduce insulin resistance and improve metabolic status.
3. For pregnant and lactating women, provide adequate energy and
nutrients needed for successful outcomes.
4. For older adults, provide for the nutritional needs of an aging
individual.
5. For individuals treated with insulin or insulin secretagogues, provide
information on prevention and treatment of hypoglycemia and
exercise-related blood glucose problems and how to manage acute
illness.
6. For individuals at risk for diabetes, decrease risk by increasing physical
activity and promoting food choices that facilitate moderate weight
loss or at least prevent weight gain.
 Food and meal plan
Integration of an insulin regimen into
usual eating habits and physical activity
schedule
 Lifestyle changes
Weight loss
Reducing energy intake
Monitoring carbohydrate serving
Limiting consumption of saturated fats
Increasing physical activity
 May improve insulin resistance and
glycemia
Energy-restricted diet
Hyperglycemia improves more rapidly than
with weight loss
Physical activity
Improves insulin sensitivity
Acutely lower blood glucose
Improves CV status
Computing for the Total Energy Requirement
Diabetic Exchange List
 In their recommendations for persons with type
2 diabetes, the 55-60% carbohydrate content
of previous diets has been reduced
considerably because of the tendency of high
carbohydrate intake to cause hyperglycemia,
hypertriglyceridemia, and a lowered HDL
cholesterol. In obese type 2 patients, glucose
and lipid goals join weight loss as the focus of
therapy. These patients are advised to limit
their carbohydrate content by substituting
noncholesterologenic monounsaturated oils
such as olive oil, rapeseed (canola) oil, or the
oils in nuts and avocados.
 Starches are rapidly metabolized into
100% glucose during digestion
Sucrose is metabolized into glucose and
fructose
Fructose has a lower glycemic index
Slight increases in plasma glucose levels
Has an adverse effect on plasma lipids
Total amount of CHO is more important
than the source of CHO
 50 of fiber reported from improved glycemic
control, reduced hyperinsulinemia, and
decreased plasma lipids
Insoluble fibers such as cellulose or
hemicellulose, as found in bran, tend to
increase intestinal transit and may have
beneficial effects on colonic function.
Soluble fibers such as gums and pectins, as
found in beans, oatmeal, or apple skin, tend to
retard nutrient absorption rates so that
glucose absorption is slower and
hyperglycemia may be slightly diminished.
 Ingested proteins do not increase
plasma glucose concentrations
Nonessential amino acids underger GNG
Protein does not slow the absorption of
carbohydrate and adding protein to the
treatment of hypoglycemia does not
prevent subsequent hypoglycemia
 < 10% of E intake should be derived from
sat fats and diet. Cholesterol intake
should be < 300 mg daily
 May cause hypoglycemia in persons
using exogenous insulin or insulin
secretagogues
Source of E
But it is not converted to glucose
Blocks GNG and augments or inc effects
of insulin by interfering with the
counterregulation response to insulin-
induced hypoglycemia
 Integral part of the treatment plan for persons
with diabetes
Improves insulin sensitivity, dec HR; reduce CV
risk factors; control weight; bring about a
healthier mental outlook; reduces amount of
bone loss associated with age and
osteoporosis
Muscular work causes insulin levels to decline
while counterregulatory hormones increase
glucose utilization by the exercising muscle
Can increase BMR, reduces appetite, helps in
the reduction of body fat
 MHR
(220-age)* PA %
PA% = 60-70%
Activity of less than 2 times a week at less
than 60% of the maximum heart rate, and
for less than 10 minutes per day, does not
assist in developing and maintaining fitness.
Twenty minutes of continuous
aerobic activity 3 days per week is
recommended for weight loss.
 Should be substituted for other
carbohydrate sources
If added, be adequately covered with
insulin or other glucose-lowering
medications
Aspartame diabetic sweetener
180x sweeter than sugar
Sucralose (Splenda)
Acesulfame potassium (Sunnet, Sweet One,
DiabetiSweet)
 Small protein consisting of 2 polypeptide
chains that are connected by disulfide
bonds
Synthesized as a precursor protein (pro-
insulin) that undergoes proteolytic
cleavage to form insulin and peptide C,
both secreted by the beta cells of the
pancreas
 Isolated from beef and pork pancreas
Human insulin is replacing the animal
hormone for therapy
Produced by a special strain of E. coli that
has been genetically altered to contain the
gene for human insulin
 Via SC injection
Preps vary in the times of onset and
duration of activity due largely to the size
and composition of insulin crystals in the
preparations
Rapid action insulin preparations
Regular insulin
Intermediate action insulin preparation
Semilente insulin suspension
Isophane insulin suspension
Lente insulin
Insulin combinations
Prolonged action insulin preparations
Ultralente insulin
 Regular insulin
Short-actig soluble crystalline zinc insulin
Usually given SC
IV during emergencies
Lowers blood sugar within minutes
Only prep suitable for IV admin
 Amorphous precipitate of insulin with
zinc ion in acetate buffer that is not
suitable for IV admin
Onset of actions and peak effect are
rapid but somewhat slower than for
regular insulin
 Aka neutral protamine Hagedorn
Suspension of crystalline zinc insulin
combined at neutral pH with a positively
charged polypeptide, protamine
Intermediate duration of action due to
delayed absorption of the insulin
because of conjugation of the insulin
with protamine to form a less soluble
complex
 A mixture of 30% semilente insulin
(prompt acting) and 70% ultralente
insulin (prolonged acting)
The combination provides a relatively
rapid absorption with a sustained action
making lente insulin the most widely used
of the lente series of insulins
Given SC
 70% isophane + 30% regular
50% or each
 Ultralente insulin
Suspension zinc insulin crystals in acetate
buffer that is composed of large particles
which are slow to dissolve slow onset of
action and a long lasting hypoglycemic
effect
MOA:
1. Stimulation of insulin release from the beta
cells
2. Reduction of serum glucagon levels
3. Increased binding of insulin to target tissues
and receptors

Primary Drugs used today:

1. Tolbutamide
2. Glyburide
3. Glipizide
 A: PO
B: serum proteins
M: liver
E: liver or kidney
CI: pts with hepatic; renal insufficiency
Delayed excretion accumulation hypoglycemia
CI: Pregnancy
Crosses the placenta deplete insulin from the fetal
pancreas
Chlorpropamide CI in the elderly
Effects are very long lastin
Has the highest incidence of SE causing hyponatremia,
hypoglycemia, and if taken with alcohol, a disulfiram
reaction
 Not stimulating insulin secretion
Metformin
May be use alone or in combi with
sulfonylureas
Acts primarily by dec hepatic glucose
output
Able to reduce hyperlipidemia and VLDL
chol conc fall; HDL chol rises
Weight loss
Drug of choice for Type 2 DM
 A: orally
B: not to serum proteins
M: not metabolized
E: urine
AE: GI; long term may interfere with B12
absorption
CI: renal and hepativ insufficiency
 Acarbose
Approved as an orally active drug for the tx of pts wit
NIDDM
Possible adjunct to insulin for those with IDDM
Inhibits a-glucosidase in the intestinal brush border
dec absorption of starch and disaccharides
Does not stimulate insulin release from the pancreas;
does not inc insulin action in peripheral tissues
Does not cause hypoglycemia
Can be used as monotherapy in those pts being
controlled by diet or in combination with oral
hypoglycemic agents or with insulin
Poorly absorbed
SE: flatulence, diarrhea, abdominal cramping