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Kind Saud University Applied Medical Science College Clinical nutrition department Educational plan for diabetic patients in KFSH Done by: Mashael Bint Mansour AL-Sultan Supervised by: Mrs. Iffat Brazey Mrs. Ohoud al Hammad Diabetes is a very big topic! To make the diagnosis, complications and treatment of diabetes more understandable, we have broken "diabetes" into several dozen diabetes topic pages which go into more and more detail. Our search engine will help you find specific diabetes information, or you can come back to this introduction page to see each of the diabetes topic pages listed. Diabetes is a disorder characterized by hyperglycemia or elevated blood glucose (blood sugar). Our bodies function best at a certain level of sugar in the bloodstream. If the amount of sugar in our blood runs too high or too low, then we typically feel bad. Diabetes is the name of the condition where the blood sugar level consistently runs too high. Diabetes is the most common endocrine disorder. Sixteen million Americans have diabetes, yet many are not aware of it. AfricanAmericans, Hispanics, and Native Americans have a higher rate of developing diabetes during their lifetime. Diabetes has potential long term complications that can affect the kidneys, eyes, heart, blood vessels, and nerves. A number of pages on this website are devoted to the prevention and treatment of the complications of diabetes. Types of Diabetes Although doctors and patients alike tend to group all patients with diabetes together, the truth is that there are two different types of diabetes which are similar in their elevated blood sugar, but different in many other ways. Throughout the remainder of these web pages we will be referring to the different types of diabetes when appropriate, but when the topic pertains to both types of diabetes we will use the general term "diabetes". Diabetes is correctly divided into two major subgroups: type 1 diabetes and type 2 diabetes. This division is based upon whether the blood sugar problem is caused by insulin deficiency (type 1) or insulin resistance (type 2). Insulin deficiency means there is not enough insulin being made by the pancreas due to a malfunction of their insulin producing cells. Insulin resistance occurs when there is plenty of insulin made by the pancreas (it is functioning normally and making plenty of insulin), but the cells of the body are resistant to its action which results in the blood sugar being too high. Type 1 diabetes is all about insulin—a lack of the hormone insulin. If you have type 1 diabetes, then your body doesn’t produce enough insulin to handle the glucose in your body. Glucose is a sugar that your body uses for instant energy, but in order for your body to use it properly, you have to have insulin. Having too much glucose in your body can cause serious complications. In order to avoid those, people with type 1 diabetes must take insulin to help their bodies use glucose effectively. Learn more about the hormone insulin and how it works. Type 1 diabetes used to be called juvenile diabetes because so many cases were noticed when patients were children. However, it is possible to develop type 1 diabetes later in life. Here’s another reason “juvenile diabetes” isn’t exactly accurate anymore: type 1 diabetes isn’t the only type of diabetes that can affect children and young adults. Type 2 diabetes is becoming more prevalent in younger people, and the treatments and causes of type 1 and type 2 are very different. It can be misleading and confusing to talk about “juvenile diabetes” when there are two distinct types that can affect children and young adults. Hearing that your child has type 1 diabetes—or that you have it—can be an overwhelming thing to take in. You’re suddenly in a new world with a new vocabulary and new requirements: hemoglobin A1c, blood glucose, insulin pumps, carb counting, diabetic ketoacidosis, etc. Type 1 diabetes develops gradually, but the symptoms may seem to come on suddenly. If you notice that you or your child have several of the symptoms listed below, make an appointment to see the doctor. Here’s why symptoms seem to develop suddenly: something triggers the development of type 1 diabetes (researchers think it’s a viral infection—read this article on what causes type 1 diabetes, and the body loses its ability to make insulin. However, at that point, there’s still insulin in the body so glucose levels are still normal. Over time, a decreasing amount of insulin is made in the body, but that can take years. When there’s no more insulin in the body, blood glucose levels rise quickly, and these symptoms can rapidly develop: Extreme weakness and/or tiredness Extreme thirst—dehydration Increased urination Abdominal pain Nausea and/or vomiting Blurry vision Wounds that don’t heal well Irritability or quick mood changes Changes to (or loss of) menstruation There are also signs of type 1 diabetes. Signs are different from symptoms in that they can be measured objectively; symptoms are experienced and reported by the patient. Signs of type 1 diabetes include: Weight loss—despite eating more Rapid heart rate Reduced blood pressure (falling below 90/60) Low body temperature (below 97º F) There is an overall lack of public awareness of the signs and symptoms of type 1 diabetes. But there are people working to promote knowledge of type 1 diabetes. And Jay Cutler, quarterback for the Chicago Bears, is one of them. To learn more about his type 1 diabetes awareness efforts, read EndocrineWeb's interview with Jay Cutler. Making yourself aware of the signs and symptoms of type 1 diabetes is a great way to be proactive about your health and the health of your family members. If you notice any of these signs or symptoms, it’s possible that you have (or your child has) type 1 diabetes. A doctor can make that diagnosis by checking blood glucose levels. Type 1 Diabetes Causes It isn’t entirely clear what triggers the development of type 1 diabetes. Researchers do know that genes play a role; there is an inherited susceptibility. However, something must set off the immune system, causing it to turn against itself and leading to the development of type 1 diabetes. Genes Play a Role in Type 1 Diabetes Some people cannot develop type 1 diabetes; that’s because they don’t have the genetic coding that researchers have linked to type 1 diabetes. Scientists have figured out that type 1 diabetes can develop in people who have a particular HLA complex. HLA stands for human leukocyte antigen, and antigens function is to trigger an immune response in the body. There are several HLA complexes that are associated with type 1 diabetes, and all of them are on chromosome 6. Different HLA complexes can lead to the development of other autoimmune disorders, such as rheumatoid arthritis, ankylosing spondylitis, or juvenile rheumatoid arthritis. Like those conditions, type 1 diabetes has to be triggered by something—usually a viral infection. What Can Trigger Type 1 Diabetes Here’s the whole process of what happens with a viral infection: When a virus invades the body, the immune system starts to produce antibodies that fight the infection. T cells are in charge of making the antibodies, and then they also help in fighting the virus. However, if the virus has some of the same antigens as the beta cells— the cells that make insulin in the pancreas—then the T cells can actually turn against the beta cells. The T cell products (antibodies) can destroy the beta cells, and once all the beta cells in your body have been destroyed, you can’t produce enough insulin. It takes a long time (usually several years) for the T cells to destroy the majority of the beta cells, but that original viral infection is what is thought to trigger the development of type 1 diabetes. Not every virus can trigger the T cells to turn against the beta cells. The virus must have antigens that are similar enough to the antigens in beta cells, and those viruses include: B4 strain of the coxsackie B virus (which can cause a range of illnesses from gastrointestinal problems to myocarditis—inflammation of the muscle part of the heart) German measles Mumps Rotavirus (which generally causes diarrhea) There have also been some controversial studies into the connection between drinking cow’s milk as an infant and the development of type 1 diabetes. Researchers don’t all agree on this, but some believe that the proteins in cow’s milk are similar to a protein that controls T cell production called glycodelin1. The baby’s body attacks the foreign protein—the cow’s milk protein—but then also attacks glycodelin, leading to an overproduction of T cells. And too many T cells in the body can lead to those T cells destroying the beta cells. Researchers have made significant progress in understanding the cause of type 1 diabetes, and they’re still hard at work to figure out why certain viruses trigger it and why T cells turn against beta cells. The medical community wants to better understand the cases of diabetes in order to prevent it. Type 1 Diabetes Risk Factors There are several risk factors that may make it more likely that you’ll develop type 1 diabetes—if you have the genetic marker that makes you susceptible to diabetes. That genetic marker is located on chromosome 6, and it’s an HLA (human leukocyte antigen) complex. Several HLA complexes have been connected to type 1 diabetes, and if you have one or more of those, you may develop type 1. (However, having the necessary HLA complex is not a guarantee that you will develop diabetes; in fact, less than 10% of people with the “right” complex(es) actually develop type 1.) Other risk factors for type 1 diabetes include: Viral infections: Researchers have found that certain viruses may trigger the development of type 1 diabetes by causing the immune system to turn against the body—instead of helping it fight infection and sickness. Viruses that are believed to trigger type 1 include: German measles, coxsackie, and mumps. For more details on how viral infections increase your risk of diabetes, read this article on the causes of type 1 diabetes. Race/ethnicity: Certain ethnicities have a higher rate of type 1 diabetes. In the United States, Caucasians seem to be more susceptible to type 1 than African-Americans and Hispanic-Americans. Chinese people have a lower risk of developing type 1, as do people in South America. Geography: It seems that people who live in northern climates are at a higher risk for developing type 1 diabetes. It’s been suggested that people who live in northern countries are indoors more (especially in the winter), and that means that they’re in closer proximity to each other— potentially leading to more viral infections. Conversely, people who live in southern climates—such as South America—are less likely to develop type 1. And along the same lines, researchers have noticed that more cases are diagnosed in the winter in northern countries; the diagnosis rate goes down in the summer. Family history: Since type 1 diabetes involves an inherited susceptibility to developing the disease, if a family member has (or had) type 1, you are at a higher risk. If both parents have (or had) type 1, the likelihood of their child developing type 1 is higher than if just one parent has (or had) diabetes. Researchers have noticed that if the father has type 1, the risk of a child developing it as well is slightly higher than if the mother or sibling has type 1 diabetes. Early diet: Researchers have suggested a slightly higher rate of type 1 diabetes in children who were given cow’s milk at a very young age. You can read more about the possible connection between cow’s milk and type 1 diabetes in this article on type 1 diabetes causes. Other autoimmune conditions: As explained above, type 1 diabetes is an autoimmune condition because it causes the body’s immune system to turn against itself. There are other autoimmune conditions that may share a similar HLA complex, and therefore, having one of those disorders may make you more likely to develop type 1. Other autoimmune conditions that may increase your risk for type 1 include: Graves’ disease, multiple sclerosis, and pernicious anemia. Diagnosing Diabetes In diagnosing diabetes, physicians primarily depend upon the results of specific glucose tests. However, test results are just part of the information that goes into the diagnosis of type 1 or type 2 diabetes. Doctors also take into account your physical exam, presence or absence of symptoms, and medical history. Some people who are significantly ill will have transient problems with elevated blood sugars which will then return to normal after the illness has resolved. Also, some medications may alter your blood glucose levels (most commonly steroids and certain diuretics, such as water pills). The two main tests used to measure the presence of blood sugar problems are the direct measurement of glucose levels in the blood during an overnight fast and measurement of the body's ability to appropriately handle the excess sugar presented after drinking a high glucose drink. Fasting Blood Glucose (Blood Sugar) Level The gold standard for diagnosing diabetes is an elevated blood sugar level after an overnight fast (not eating anything after midnight). A value above 140 mg/dl on at least two occasions typically means a person has diabetes. Normal people have fasting sugar levels that generally run between 70-110 mg/dl. The Oral Glucose Tolerance Test An oral glucose tolerance test is one that can be performed in a doctor's office or a lab. The person being tested starts the test in a fasting state (having no food or drink except water for at least 10 hours but not greater than 16 hours). An initial blood sugar is drawn and then the person is given a "glucola" bottle with a high amount of sugar in it (75 grams of glucose or 100 grams for pregnant women). The person then has their blood tested again 30 minutes, 1 hour, 2 hours, and 3 hours after drinking the high glucose drink. For the test to give reliable results, you must be in good health (not have any other illnesses, not even a cold). Also, you should be normally active (for example, not lying down or confined to a bed like a patient in a hospital), and you should not be taking any medicines that could affect your blood glucose. The morning of the test, you should not smoke or drink coffee. During the test, you need to lie or sit quietly. The oral glucose tolerance test is conducted by measuring blood glucose levels five times over a period of 3 hours. In a person without diabetes, the glucose levels in the blood rise following drinking the glucose drink, but then they fall quickly back to normal (because insulin is produced in response to the glucose, and the insulin has a normal effect of lowing blood glucose). In a diabetic, glucose levels rise higher than normal after drinking the glucose drink and come down to normal levels much slower (insulin is either not produced, or it is produced but the cells of the body do not respond to it). As with fasting or random blood glucose tests, a markedly abnormal oral glucose tolerance test is diagnostic of diabetes. However, blood glucose measurements during the oral glucose tolerance test can vary somewhat. For this reason, if the test shows that you have mildly elevated blood glucose levels, the doctor may run the test again to make sure the diagnosis is correct. Glucose tolerance tests may lead to one of the following diagnoses: Normal Response A person is said to have a normal response when the 2-hour glucose level is less than or equal to 110 mg/dl. Impaired Fasting Glucose When a person has a fasting glucose equal to or greater than 110 and less than 126 mg/dl, they are said to have impaired fasting glucose. This is considered a risk factor for future diabetes, and will likely trigger another test in the future, but by itself, does not make the diagnosis of diabetes. Impaired Glucose Tolerance A person is said to have impaired glucose tolerance when the 2hour glucose results from the oral glucose tolerance test are greater than or equal to 140 but less than 200 mg/dl. This is also considered a risk factor for future diabetes. There has recently been discussion about lowering the upper value to 180 mg/dl to diagnose more mild diabetes to allow earlier intervention and hopefully prevention of diabetic complications. Diabetes A person has diabetes when oral glucose tolerance tests show that the blood glucose level at 2 hours is equal to or more than 200 mg/dl. This must be confirmed by a second test (either one) on another day. There has recently been discussion about lowering the upper value to 180 mg/dl to diagnose more people with mild diabetes to allow earlier intervention and hopefully prevention of diabetic complications. To keep up on diabetes advances, sign up for our FREE Diabetes eNewsletter. Get meal planning and exercise tips, plus advice from leading specialists. Gestational Diabetes A woman has gestational diabetes when she is pregnant and has any two of the following: a fasting plasma glucose of more than 105 mg/dl, a 1-hour glucose level of more than 190 mg/dl, a 2-hour glucose level of more than 165 mg/dl, or a 3-hour glucose level of more than 145 mg/dl. Type 2 Diabetes Type 2 Diabetes is more common than Type 1 Diabetes. Whereas type 1 diabetes is characterized by the onset in young persons (average age at diagnosis = 14), type 2 diabetes usually develops in middle age or later. This tendency to develop later in life has given rise to the term "adult onset diabetes," although the prevalence of type 2 diabetes in younger people is rising, making this term somewhat inaccurate and outdated. The typical type 2 diabetes patient is overweight ,although there are exceptions. In contrast to type 1 diabetes, symptoms often have a more gradual onset. Type 2 diabetes is associated with insulin resistance rather than the lack of insulin, as seen in type 1 diabetes. This often is obtained as a hereditary tendency from one's parents. Insulin levels in these patients are usually normal or higher than average but the body's cells are rather sluggish to respond to it. This lack of insulin activity results in higher than normal blood glucose levels. Incidence of Type 2 Diabetes Type 2 diabetes is the most common type of diabetes. This disease exists in all populations, but prevalence varies greatly, ie, 1% in Japan, and greater than 40% in the Pima Indians of Arizona. In Caucasians, the figure is somewhere between 1-2% of the entire population. The high incidence of type 2 diabetes in certain groups such as the Pima Indians appears to be a relatively recent development that followed a change in the type of food intake (from relatively little food to plenty of food). With this came the development of obesity within their culture which results in diabetes developing in those that are genetically predisposed. This "urbanization phenomenon" has been most carefully studied in nonwhite populations, but is probably ethnically and racially nonspecific. In other words, obesity tends to promote diabetes in those genetically predisposed regardless of where you live and what your racial background is. Hereditary Aspects of Type 2 Diabetes Type 2 diabetes tends to be fairly hereditary in contrast to type 1 diabetes. Approximately 38% of siblings and one-third of children of people with type 2 diabetes will develop diabetes or abnormal glucose metabolism at some point. The degree of obesity also seems to be a factor, with a larger percentage of diabetes developing in those who are more obese. Studies with identical twins showed that 90-100% of the time when diabetes developed in one it would also develop in the other compared with 50% in type 1 diabetes. Causes of Type 2 Diabetes Development of type 2 diabetes seems to be multi-factorial; that is, there are a number of issues to blame. Genetic predisposition seems to be the strongest factor. Obesity and high caloric intake seem to be another. Twenty percent of people with this type 2 diabetes have antibodies to their islet cells which are detectable in their blood resulting in the expected low levels of insulin, suggesting the possibility of incomplete islet cell destruction (see discussion about autoimmune diabetes in the type 1 diabetes section). These patients often tend to respond early to oral drugs to lower blood sugar but may need insulin at some point. More about Type 1 Diabetes Making the Diagnosis of Diabetes How Insulin Regulates Blood Glucose Levels Treatment of Diabetes Assessing how well Glucose is Controlled in a Diabetic The Symptoms of Hyperglycemia More about the production of hormones by Islet Cells of the Pancreas Back to Diabetes Introduction Sign up for our FREE Diabetes eNewsletter! Get meal planning and exercise tips, plus advice from leading specialists! Complications The parts of the body that can be most affected by diabetes complications are the: eyes kidneys nerves heart and blood vessels gums feet Eye Problems People with diabetes have a greater risk of developing eye problems, including: Cataracts: A cataract is a thickening and clouding of the lens of the eye. The lens is the part of the eye that helps you focus on what you see. Cataracts can make a person's vision blurry or make it hard to see at night. Doctors think that people with diabetes are more likely to develop cataracts if they have high blood sugar levels over a long period of time. If cataracts get in the way of seeing properly, a person can have surgery to remove them. Retinopathy: Another eye problem, called diabetic retinopathy (pronounced: reh-tih-nah-puh-thee), involves changes in the retina, the light-sensitive layer at the back of the eye. These changes happen because of damage or growth problems in the small blood vessels of the retina. Usually, changes in the retinal blood vessels don't appear before a person has reached puberty and has had diabetes for several years. Retinopathy is more likely to become a problem in people with diabetes if they have high blood sugar levels over a long period of time, if they have high blood pressure, or if they use smoke or chew tobacco. One reason why teens with diabetes need to have regular yearly eye exams is because people with retinopathy may not have any problems seeing at first. But if the condition gets worse, they can become blind. If a person develops retinal problems, he or she will need to visit the eye doctor more often. A person with diabetes may be able to slow or reverse the damage caused by retinopathy by improving blood sugar control. If retinopathy becomes more advanced, laser treatment may be needed to help prevent vision loss. Glaucoma: People who have diabetes also have a greater chance of getting glaucoma. In this disease, pressure builds up inside the eye, which can decrease blood flow to the retina and optic nerve and damage them. At first, a person may not have trouble seeing. But if it's not treated, glaucoma can cause a person to lose vision. The risk increases as a person gets older and has had diabetes longer. People with glaucoma take medications to lower the pressure inside the eye and sometimes need surgery. Your doctor will probably check your eyes for early signs of these problems during routine exams. He or she may also recommend that you see an ophthalmologist (pronounced: opf-thul-mah-luh-jist, a doctor who specializes in treating diseases of the eye) or optometrist (pronounced: op-tahmuh-trist, a person who examines your eyes and tests your vision). Keeping your blood sugar and blood pressure levels under control and avoiding tobacco may also help you avoid eye problems associated with diabetes. Kidney Disease When blood sugar is high, it can cause damage to the blood vessels in the kidneys, leading to kidney disease. This is sometimes called diabetic nephropathy (pronounced: nehfrah-puh-thee). Kidney disease is more likely to happen in people who haven't controlled their blood sugar levels over a long period of time. If a person develops kidney disease, it can get worse if he or she has high blood pressure or uses tobacco. In its early stages, kidney disease doesn't cause symptoms. Over time, though, kidney disease can cause kidney failure, which means the kidneys stop working. So kidney disease is a serious health problem. If a person has gone through puberty and has had diabetes for several years, doctors will probably test for kidney disease about once a year. Doctors may do a urine test to measure the amount of protein called albumin (pronounced: al-byoo-mun) in the urine. If the amount of protein in the urine increases beyond a certain point, or if there are other signs of kidney disease, doctors may look at a piece of the kidney under a microscope to make sure a person really has kidney disease. If doctors detect kidney disease early enough, the damage can sometimes be reversed with proper treatment. Doctors may tell a person with diabetic nephropathy to eat less protein. They may also prescribe medications. If the kidney disease gets worse, a person may develop kidney failure, which requires dialysis (regular use of a machine to clean the blood as the kidneys normally would) or a kidney transplant. The good news is that these days kidney disease is less likely to end up as kidney failure because of earlier detection and better treatment than in the past. The best way to help prevent diabetic kidney disease is to keep your blood sugar levels under control by following your diabetes treatment plan. It's also important to get regular blood pressure checks and urine albumin tests — your diabetes health care team will tell you when you need these. In addition, steer clear of smoking, which can increase the risk of kidney problems and other diabetes complications and health problems. Nerve Damage Another complication that people who have had diabetes for a long time may develop is a type of nerve damage called diabetic neuropathy (pronounced: noo-rah-puh-thee). Diabetic neuropathy can affect nerves in many different parts of the body. The most common early symptoms of the condition are numbness, tingling, or sharp pains in the feet or lower legs. If it's not treated, nerve damage can cause a number of problems. For example, because of the numbness, people with nerve damage might not realize that they have a cut, and it could become seriously infected before they discover it. Because nerve damage can happen anywhere in the body, problems can occur in almost any organ system, including the digestive tract, urinary system, eyes, and heart. Doctors usually diagnose nerve damage by giving a person a physical exam. A biopsy of nerve tissue or other special tests may also be necessary. The doctor might recommend that the patient see a nerve specialist (neurologist). Doctors believe nerve damage is linked to high blood sugar levels over time. So controlling blood sugar levels by following a diabetes treatment plan can help reduce a person's risk of developing this complication. Heart and Blood Vessel Diseases People with diabetes have a higher risk of developing certain problems with the heart and blood vessels. (These are called cardiovascular diseases.) Some of these problems are: heart attack (caused by a blockage of the blood vessels supplying blood to the heart) stroke (caused by a blockage of the blood vessels supplying the brain) blockage of blood vessels in the legs and feet, which can lead to foot ulcers, infections, and even loss of a toe, foot, or lower leg How well a person controls his or her blood sugar probably plays a role in heart and blood vessel problems, too. And if a person smokes, is obese, has abnormal levels of blood lipids (triglycerides or cholesterol), high blood pressure, or a family history of heart attack or stroke before age 50, he or she definitely has a higher risk of these problems. One thing you can do to reduce your risk of cardiovascular diseases is to be a healthy weight. If you're overweight, your doctor can suggest ways to help you lose weight and stay there. The doctor may also check your blood lipid levels (cholesterol and triglycerides) and blood pressure regularly to be sure they're in a healthy range. Following your diabetes meal plan, getting regular exercise, and taking diabetes medications as prescribed may also help prevent or delay the development of heart and blood vessel problems. In addition, smoking increases the risk of heart and blood vessel problems, as well as other diabetes complications. Gum Disease People with diabetes are more likely than others to develop gum disease (also called periodontal disease) because they may have: more plaque and less saliva (too much plaque on the teeth and not enough saliva can contribute to tooth decay) higher blood sugar levels (a person has more sugar in their mouth, which can also lead to tooth decay) some loss of collagen, a protein that's in gum tissue poor blood circulation in the gums All of these factors can contribute to gum disease. Signs and symptoms of gum disease include bleeding, sensitive, and painful gums. A person's gums may also recede (receding gums is a term that means the gum tissues no longer cover the root surfaces of teeth), or be discolored. Dentists can diagnose gum disease during regular checkups. Fortunately, you can prevent gum disease by managing your blood sugar levels, taking good care of your teeth by brushing and flossing daily, and getting regular dental checkups. Foot Problems After a person has had diabetes for many years, he or she can develop foot problems because of poor blood flow in the feet and nerve damage. Starting at puberty, your doctor will check your feet for any signs of problems. You should tell your doctor about any foot problems you're having, such as ingrown toenails, calluses, and dry skin. Even if your feet just feel irritated because you've been wearing certain shoes or because you've had a minor sports injury, you should tell your doctor. To prevent foot problems, wear comfortable shoes that fit properly and keep your toenails trimmed to the shape of the toe. Exercise, which increases blood flow to the feet, can also help keep feet healthy. Smoking can increase the risk of foot problems or make them worse. Staying Healthy for the Long Haul Some complications of diabetes occur after years — even decades — of having the disease, and sometimes people don't even have any noticeable symptoms. That's why it's so important to follow your diabetes management plan and taking an active role in your health by getting regular medical care and checkups with your diabetes health care team. They can detect many diabetes problems before they start causing symptoms and help you get the treatment you need. Treatment of Diabetes There are several aspects in the treatment of diabetes, each one with a very important role. The mainstays of diabetes treatment are: 1. 2. 3. 4. Working towards obtaining ideal body weight Following a diabetic diet Regular exercise Diabetic medication if needed Note: Type 1 diabetes must be treated with insulin; if you have type 2 diabetes, you may not need to take insulin. This involves injecting insulin under the skin for it to work. Insulin cannot be taken as a pill because the digestive juices in the stomach would destroy the insulin before it could work. Scientists are looking for new ways to give insulin. But today, shots are the only method. There are, however, new methods to give the shots. Insulin pumps are now being widely used and many people are having great results. Working towards obtaining ideal body weight An estimate of ideal body weight can be calculated using this formula: For women: Start with 100 pounds for 5 feet tall. Add 5 pounds for every inch over 5 feet. If you are under 5 feet, subtract 5 pounds for each inch under 5 feet. This will give you your ideal weight. If you have a large frame, add 10%. If you have a small frame, subtract 10%. A good way to decide your frame size is to look at your wrist size compared to other women's. Example: a woman who is 5' 4" tall and has a large frame. 100 pounds + 20 pounds (4 inches times 5 pounds per inch) =120 pounds. Add 10% for large frame (in this case 10% of 120 pounds is 12 pounds). 120 pounds + 12 pounds = 132 pounds ideal body weight. For men: Start with 106 pounds for a height of 5 foot. Add 6 pounds for every inch above 5 foot. For a large frame, add 10%. For a small frame, subtract 10%. (See above for further details). The Diabetic Diet Diet is very important in diabetes. There are differing philosophies on what is the best diet but below is a guideline with some general principles. Patients with type 1 diabetes should have a diet that has approximately 35 calories per kg of body weight per day (or 16 calories per pound of body weight per day). Patients with type 2 diabetes generally are put on a 1500-1800 calorie diet per day to promote weight loss and then the maintenance of ideal body weight. However, this may vary depending on the person's age, sex, activity level, current weight and body style. More obese individuals may need more calories initially until their weight is less. This is because it takes more calories to maintain a larger body and a 1600 calorie diet for them may promote weight loss that is too fast to be healthy. Men have more muscle mass in general and therefore may require more calories. Muscle burns more calories per hour than fat. (Thus also one reason to regularly exercise and build up muscle!) Also, people whose activity level is low will have less daily caloric needs. Generally, carbohydrates should make up about 50% of the daily calories (with the accepted range 40-60%). In general, lower carbohydrate intake is associated with lower sugar levels in the blood. However the benefits of this can be cancelled out by the problems associated with a higher fat diet taken in to compensate for the lower amount of carbohydrates. This problem can be improved by substituting monounsaturated and polyunsaturated fats for saturated fats. Most people with diabetes find that it is quite helpful to sit down with a dietician or nutritionist for a consult about what is the best diet for them and how many daily calories they need. It is quite important for diabetics to understand the principles of carbohydrate counting and how to help control blood sugar levels through proper diet. Below are some general principles about the diabetic diet. Understanding Food Groups There are three basic food groups: fats, proteins, and carbohydrates. The carbohydrates are the foods that can be broken down into sugar. It is essential to have all three food groups in your diet to have good nutrition. 1. Why Count Carbohydrates? Carbohydrates make your blood glucose level go up. If you know how much carbohydrates you've eaten, you have a good idea what your blood glucose level is going to do. The more carbohydrates you eat, the higher your blood sugar will go up. 2. Which Foods Contain Carbohydrates? Most of the carbohydrate we eat comes from three food groups: starch, fruit, and milk. Vegetables also contain some carbohydrates, but foods in the meat and fat groups contain very little carbohydrate. Sugars may be added or may be naturally present (such as in fruits). The nutrient term for sugars can also be identified by looking for -ose at the end of a word ( i.e, glucose, fructose, and sucrose are all sugars). Look for these on food labels to help identify foods that contain sugar. 2. Goal: Improve nutritional status among diabetic patients in KFSH. 3. Objectives: Patients will be able to list nutritional related problems related to his condition Patients will be able to list 5 food items low in suger. Patients will be able to list the 5 foods to avoid. Patients be able to explain the right way to prepare food. Patients will be able to list nutritional related problems related to his condition. Patients will be able to identify food that raises blood glucose level. Patient will be able to do blood glucose test. 4. Target Group: Diabetic patients in KFSH male and female. 5. Location: King Faisal Specialist Hospital 6. Time: Feb. 2010 – Feb. 2011 7. Plan: I'm going to implement my program by individual teaching and group teaching. And patients will be given written material and will see visual display of the given information. So at the end of the program the goal will be fulfilled. 8. Individual Teaching: a. Objectives: Patient will be able to list the food allowed in every stage of his diet. Patient will be able to explain the importance of good nutrition on her status. Patient will be able to list 5 food to avoid Patient will be able to identify the foods that raises blood glucose level Patient will be able to do blood glucose test. b. Session plan: 3 sessions and 4 follow-ups in the giving time. Lab results and physical diagnoses will be included. Session 1: Location: in patient room Introduce myself and explain why am seeing the pt. Address pt's concerns and worries and his health status. His labs and blood glucose level. Give him an idea about the diet he will follow. Low sugar low fat diet, high fiber. What is a good life style? Session 2: Location: in patient room Ask pt about his appetite, if he is liking the food or not. Healthy food habits, blood glucose level. If he has any kind of complications or questions. Explain the importance of exercise. Schedule next appointment in out patient clinic with the doctor appointment. Session 3: Ask pt. about the diet he is following, and if he is having any nutritional related problems, his blood glucose level. And check on pt lab results. And discuss it with the patient. c. Follow up sessions: 4 Check ups on paints lab results and compliance by testing patient. Monitor his labs and weight change. If pt is having any nutritional deficiency. d. Time: First session first day patient is admitted (10 min maximum) Second session before discharge (15-30 minutes) Third session is out patent clinic with doctor’s appointment (15-30 minutes) Follow up with doctor’s appointment every 3 months. e. Location: Dietitian's office and in patient room at KFSH. f. Material: Food samples, presentations, brochure, menu g. Evaluation: Pre/post test in every session. Lab results and weight change. h. Documentation: In dietitian's note in the pt's file. 9.Group Teaching: a. Objectives: Group will be able to do blood glucose test. Group will know the importance of exercise and healthy life style, and loosing weight if needed. Group will be able to name to avoid food high sugar high fat. Group will be able to identify nutritional related problems to their condition . Group will share experiences and successful strategies . b. Session plan: Introduce myself and then explain what is Diabetes. c. Time: Every 1st Monday of every month. d. Location: Waiting area of the Diabetic clinic e. Material: Presentation. f. Evaluation: Self-administered questioner g. Documentation: In my program file. 10.Material: Presentation, Food models, menus, brochures and displays 11.Tools: Computer, printer, phone. 12.Referral: My pager No. Clinic extenuation 13.Health Care: Lab workers, doctors and nurses 14.Final Evaluation: Lab results and questioners 15.Documentation: Report to the administration. Publish results in the hospital journal.