Prediabetes
Impaired pasting glucose or impaired glucose tolerance. High risk of developing T2DM. Aggressive lifestyle change. |
Insulin resistance
↑ insulin production to try and keep up (chronic hyperinsulinemia) = body becomes less sensitive to it = exhaust the beta cells “burn out” = decline in function = ↓ insulin (alongside resistance) |
Progression: beta cells fail to compensate, leading to insulin deficiency alongside resistance |
Treatment = Lifestyle. ↓ weight, ↑ exercise. Education on progression. |
Metabolic syndrome
Central adiposity (measured by waist circumference) PLUS AT LEAST ONE OF: |
↑ triglycerides (>1.7mmol/L) |
↓ HDL (males <1.03, females <1.29) |
↑ BP (S >130, D >85) |
Fasting BGL >5.6mmol/L |
Diagnosed T2DM |
T2DM
Defective insulin receptors → Cells cannot efficiently take up glucose = ↑ blood glucose levels. Compensatory hepatic response → The liver ↑s gluconeogenesis |
Insulin resistance AND relative insulin deficiency |
Risk factors: age, family hx, obesity, sedentary lifestyle, HT, dyslipidaemia, impaired glucose tolerance, ethnicity, insulin resistance |
Consider
prev education/age on diagnosis |
how they take their medication |
insulin? |
Diagnosis
FBG: >7 mmol/L (confirmed with repeat) |
FBG: >7 mmol/L AND 2h glucose >11.1 mmol/L |
Hb1c >6.5% (confirmed with repeat) |
S/S
Hypo |
Hyper |
Trembling |
3 Ps |
Trouble concentration |
blurred vision |
Sweating |
weight loss |
↑ HR |
fatigue |
Dizzy |
low energy |
Weakness |
delayed healing |
| |
irritability |
Consequences
retinopathy (vision loss or blindness) |
nephropathy (leading cause of CKD) |
neuropathy – numbness/feet - amputations |
stroke |
delayed wound healing - infections |
|
|
Biochem
BGL |
Glucose, random |
3.0-7.7 mmol/L |
Glucose, fasting |
3-6 mmol/L |
Impaired, fasting glucose |
6.1-6.9 mmol/L |
Diabetic, fasting glucose |
> 7 mmol/L |
Insulin |
5-25 mmol/L |
OGTT |
OGTT (normal) |
3-7.7 mmol/L |
OGTT (impaired) |
7.8-11 mmol/L |
OGTT (probable diabetic) |
>11.1 mmol/L |
HbA1c |
long-term indicator of blood glucose control |
Normal range |
3.5-6% |
Prediabetes |
6-6.4% |
Diabetes |
>6.5% |
Good control |
<7% |
Poor Control |
>8.1% |
MNT Objectives
Fasting blood glucose 6–8 mmol/L |
HbA1c <7% |
Moderate weight loss if overweight (5–10% of body weight) |
CHO consistency across meals |
Contact: 3-6 encounters in first 6 months. Min 1 annual review. |
Nut Reqs
Na <2 300 mg/day |
Fibre intake ≥38g/day |
Strategies
Weight Management |
↑ exercise, portion control, ↑ lean P/Fibre, meal plans, swaps |
Carb counting |
1 carb choice/exchange = 15g CHO. 2-4 exchanges per meal (30-60g CHO). 1–2 carb exchanges per snack. Label reading, sugar-free substitutes |
CHO consistency |
↑ complex carbs, even spacing throughout the day |
GI |
Lower GI foods and “dressing up” CHO |
Group counselling |
Carb Counting
1 exchange (15g CHO) |
1 sl bread |
1/2 bread roll |
1/2 english muffin |
2-4 multigrain crackers (eg vitaweat) |
1 crumpet |
1/3 cup raw oats |
1/2 cup muesli |
1 1/2 weetbix |
½ cup cooked pasta |
¼ cup cooked rice |
1/3 cup cooked noodles |
1 small potato |
1 medium cob corn |
|
|
Example PESS
Inappropriate intake of types of carbohydrates (intake), related to food/nutrition knowledge deficit, as evidenced by CHO intake/CHO distribution ratio/FBG |
Medications
Metformin |
↑ insulin sensitivity. ↓ liver glucose. S/E: metallic taste, N/D. Tablet taken w/ food. |
Alogliptin, Linagliptin, Saxagliptin, Sitagliptin, Vildagliptin |
↑ insulin production. ↓ liver glucose. S/E: GI upset. Tablet. |
GLP-1 (e.g. Ozempic/Semaglutide) |
↑ insulin production. ↓ stomach emptying. N/V/D, weight loss, appetite suppression. Injection twice a day, or once a week |
SGLT2 inhibitor. Dapagliflozin, Empagliflozin, Ertugliflozin |
↑ glucose loss in urine. Tablet taken w/ water. S/E: dehydration (↑ urination), ↓ BP, weight loss, ketoacidosis. Avoid if eating a very low CHO diet. |
Sulfonylurea Glibenclamide, Gliclazide, Glipizide, Glimepiride |
↑ insulin production. S/E: N/D, hypoglycaemia, weight gain. |
INSULIN Injections
|
Background: control fasting blood glucose levels. 1-2/day regardless of mealtimes. Long-acting (onset 2.4h, duration ~24): TOUJEO, OPTISULIN. Intermediate-acting (onset 0.5-1h, duration 10-16h): PROTAPHANE, HUMULIN NPH
|
|
Bolus: Quickly reduce high blood glucose levels Rapid acting (onset 5 mins, duration 4.5 hours). NOVORAPID, HUMALOG, APIDRA, FIASP. Taken immediately after a meal. Short acting. (onset 30 mins, duration 6 hours). ACTRAPID, HUMULIN R. Taken 15-30 mins before meal.
|
|
Premix: Mix of background & bolus. Best taken at regular times of the day with a meal Analogue (onset 5-15min, duration 10-16h). NOVOMIX30, HUMALOG MIX 25, HUMALOG MIX 50, RYZODEG 70 Human (onset 30min, duration 10-16h). MIXTARD 30, MIXTARD 50.
|
|
Important to have carbs at every meal and avoid skipping meals. |
Guidelines & References
Muscogiuri et al. Nutritional guidelines for the management of insulin resistance. Critical reviews in food science and nutrition, 2022 |
A Position Statement on Screening and Management of Prediabetes in Adults 2020 |
Lifestyle management. (2017). Diabetes Care |
Management of type 2 diabete mellitus: A handbook for general practice. RACGP, 2021 |
Papamichou et al. Dietary patterns and management of type 2 diabetes: a systematic review of randomised clinic trials. (2019) |
Nutrition therapy recommendations for the management of adults with diabetes. Diabetes Care (2013) |
Handbook p131 |
|
