Introduction

Diabetes mellitus (DM) is a progressive disease, which disrupts carbohydrate, protein and fat metabolism and results in hyperglycemia. The metabolic disturbances characteristic of DM occur due to a lack of insulin or resistance to the effects of insulin at target organs. There are four principle classes of DM: pre-diabetes, Type 1, Type 2 and gestational diabetes.

Pre-diabetes is a condition in which blood glucose is elevated above normal but not high enough to be classified as diabetes. As many as 57 million Americans currently have pre-diabetes. Without intervention, pre-diabetes can progress to diabetes in as few as ten years. Pre-diabetes can cause damage to the cardiovascular system long before DM is diagnosed. However, studies have shown that progression from pre-diabetes to diabetes in not inevitable. Medical nutrition therapy (MNT), and regular physical activity can reduce the risk of developing DM. The American Diabetes Association (2009) recommends, "Individuals who have pre-diabetes or diabetes should receive individualized MNT as needed to achieve treatment goals, preferably provided by a registered dietitian familiar with the components of diabetes MNT". The goals of diabetes MNT are to assist the patient to safely attain and maintain nutrition and lifestyle changes that reduce the risk of complications associated with diabetes.

Type I DM is the result of autoimmune destruction of pancreatic beta cells. Type I accounts for 5-10% of DM. The onset of Type 1 usually occurs in childhood or young adulthood. Risk factors for Type 1 DM include genetic propensity and environmental exposures that trigger an autoimmune response. Type 1 diabetics require exogenous insulin to manage their disease. Without exogenous insulin, skeletal muscle and fat are unable to lower blood glucose by absorbing and storing excess glucose. Without insulin, the pancreatic hormone glucagon is free to mobilize hepatic glycogen, skeletal muscle protein, and fatty acids in a futile attempt to provide the body with fuel. The end result is hyperglycemia and its associated pathologies. The treatment of Type 1 DM in adults focuses on: correction of acute health conditions, MNT, self-care education, self-monitoring of blood glucose (SMBG)), insulin therapy and the management of late complication.

Type 2 DM accounts for about 90% to 95% of all diagnosed cases of DM. Type 2 is associated with older age, obesity, family history of diabetes, history of gestational diabetes, impaired glucose metabolism, physical inactivity, and race/ethnicity. Type 2 DM used to be known as adult onset diabetes, but since the late 1990's it is increasingly being diagnosed in children and adolescents. Type 2 DM patients produce insulin but the quantity may be insufficient or the target organs may not respond. Type 2 is often a progressive disease but nutrition and lifestyle changes have been shown to slow or halt the disease process. Treatment of type 2 DM focuses on weight loss, MNT, physical exercise, continuing medical care and self-management.

Gestational diabetes mellitus (GDM) is a growing health risk to both the mother and child. A large study in Los Angeles County, California found that the prevalence of gestational diabetes increased threefold from 14.5/1000 singleton deliveries in 1991 to 47.9/1000 singleton deliveries in 2003. GDM is defined as any glucose intolerance that manifests during a pregnancy. There are two forms of GDM. The first is induced by pregnancy related endocrine factors. The second is a chronic maternal insulin resistance that is unmasked by pregnancy. Management of GDM includes individualized medical nutrition therapy, daily self-monitoring blood glucose, planned physical activity and insulin when needed.

It is vital to involve the diabetic person’s family and significant others in the diabetes care plan. These individuals purchase and prepare food, provide encouragement and support for the person with diabetes. Diabetic individuals often find that making nutritional changes to be one of the greatest challenges they face in disease management. A successful treatment plan will incorporate nutrition and lifestyle changes the patient is willing and able to make.

Cultural and ethnic considerations are also important. All persons with diabetes, whatever their age, type of diabetes or disease severity, must be made aware of the vital importance of dietary management. In American culture, food is often associated with love and rewards. Handing a newly diagnosed diabetic person a pre-printed diet, without carefully personalizing the plan to each unique individual, will not work for most people with diabetes.


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