The treatment of diabetes aims to obtain a hemoglobin value as close as possible to normal without giving up a comfortable life. In this sense, various factors come into play, such as insulin injection, diet or physical activity.

Diet and diabetes

In order to successfully control diabetes, it is essential to implement certain healthy lifestyle habits among which food plays an essential role. Below  we will see some fundamental aspects of diet for people with diabetes.

    The diet should be personalized based on the type of diabetes, age, weight, physical activity and type of drug treatment.

    It has to be a healthy and balanced diet based on the principles of the Mediterranean diet.

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    It is necessary to restrict the consumption of rapidly absorbing carbohydrates, alcohol and animal fats.

    It is important to respect meal times and not skip any intake.

Basic nutrients

Thanks to food, the body receives nutrients, which are essential substances for its functioning. The basic nutrients are carbohydrates (sugars), fats, proteins, vitamins, minerals and water.

Carbohydrates are the most important source of energy, and for the body to be able to use them, it is necessary the existence of insulin, a hormone that is produced in the pancreas and that is fundamentally secreted every time food is ingested.

In diabetes, the total or partial defect of insulin can alter the nutrition of the body’s cells. For this reason, it is necessary to use the right medication and eat in a healthy way.

The diet recommended for people with diabetes does not differ significantly from that which the general population should follow. In short, it is based on an overall caloric reduction – in those people who need it because they are overweight – and a balanced distribution of the different nutrients.

Characteristics of the power supply

The diet a person needs depends on their individual needs, which are defined by weight, height, sex and physical activity. It should be remembered that one of the best resources to achieve adequate control of sugar levels in diabetes is to achieve and maintain an adequate diet and weight.

The basic lines in the diet of people with diabetes can be summarized in what is meant by “Mediterranean diet”, and does not differ excessively from a healthy diet for anyone, except in the greater control of the portions or use of sugars and sweeteners.

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Recommendations

    Eat several times a day, avoiding copious intakes.

    Restrict fast-absorbing sugars (refined sugars, fruit juices, cakes, sweets, pastries in general) because they sharply raise blood glucose levels.

    Use foods with slow-absorbing carbohydrates such as legumes, Italian pasta, bread, potatoes, rice, etc., since especially the first two produce a milder elevation of blood glucose.

    Use high-fiber foods such as vegetables, for the same reason as above.

    Limit foods of animal origin, also ensuring that the consumption of fish exceeds that of meat.

    Reduce fats that are contained in sausages, cheeses, meats in general, butters and margarines.

    Limit egg consumption, especially in those who have high cholesterol.

    In adults, consider the consumption of moderate amounts of alcohol, especially in the form of wine (1-2 glasses daily).

    Use olive oil, especially for cooking.

Diet foods and sweeteners

So-called “regimen” foods or dietary products are made in such a way that the original composition has been modified to increase, decrease or replace some of its ingredients. For example, foods enriched in fiber, with less fat or salt, without alcohol, with saccharin instead of sugar, etc.

Should I use sweeteners?

Sweeteners and diabetes

Dietary products and sweeteners, used with moderation and critical judgment, can be included in a healthy diet. Healthy eating should contain a wide range of flavors.

Keep in mind that the sweet taste is rewarding and is associated with all kinds of celebrations and parties (anniversary cake, wedding cake, Christmas, etc.), and its enjoyment should not be prohibitive for the person with diabetes. They should not form the basis of our diet, but they can be the complements of a healthy diet, for example:

Foods enriched in fiber (to increase the feeling of satiety, regulate the intestine, slow the absorption of sugar,… ).

    “Light” foods and beverages with synthetic sweeteners (saccharin, cyclamate, etc.) that allow you to enjoy the sweet taste without raising blood glucose or providing calories.

    Unsalted products (such as unsalted bread or others) that are

    useful in the control of hypertension.

A characteristic of most sweeteners is that they provide a greater sensation of sweetness than the sugar itself. During pregnancy it is advisable to use them as little as possible, opting for aspartame in the first place.

Abuse of some sweeteners such as sorbitol (in candies, chewing gum, etc.) can lead to diarrhea.

Important aspects of labeling

Sweeteners must be listed as ingredients on the label of processed products. All “regimen foods” that are not properly labelled should be rejected.

Keep in mind that it is possible for foods labeled with expressions

of the “no added sugar, tolerated for diabetics” type contain natural sweeteners that increase blood sugar.

Some pastry or chocolate products or ice cream called “dietetics” have been modified in the type or amount of sugars  but continue to provide similar amount of fats, usually unhealthy.

Physical activity and diabetes

Physical exercise is one of the fundamental pillars in the treatment of diabetes, along  with diet, pharmacological treatment and health education. Physical activity is highly recommended for everyone, but it is especially useful for people with diabetes. However, it must be carried out in a controlled manner, paying special attention in times of complications or lack of control of the disease.

It is necessary to control all the factors that can influence blood glucose (especially diet and medication) and adapt them to the physical activity that will be performed. In this way, the risk of diabetes decompensations can be reduced.

    The practice of physical exercise should be regular and stable over time

    It is recommended to do 150 minutes per week of aerobic physical activity and moderate-intense intensity, divided over 3 days per week

    It is advisable to choose the type of exercise to be performed based on personal preferences, previous physical condition and other concomitant diseases.

What happens while a person with diabetes is exercising?

During the practice of physical exercise there is an increase in fuel consumption by the muscle. In the first 30 minutes, the muscle uses glucose from its own deposits, but when these are depleted it has to consume glucose from the blood.

Consequently, a continuous supply is established from the liver, which also produces glucose, to the blood and from the blood to the muscle. If exercise is prolonged and there is no more glucose to use, fuel is obtained from fats.

What benefits does exercise bring to the person with diabetes?

    It helps improve diabetes control.

    It favors weight loss, due to the consumption of fats by the muscle in activity.

    Improves muscle elasticity.

    Reduces the incidence of cardiovascular disease.

    It provides a reduction in the dose of insulin, if the sports practice is regular.

    It has obvious psychic benefits, making the person feel better.

What exercises are the most and least recommended?

Walking or running gently for about 30-40 minutes, at least 3 days a week, without making sudden changes of pace, is one of the most recommended exercises for most people with diabetes.

To know if the exercise is adequate, the intensity can be controlled by measuring our heart rate. The ideal is to reach 60-70% of the maximum heart rate, calculated with the formula 220 minus age.

Exercises and sports that require a sustained effort (such as endurance or long-term) preferably use aerobic metabolism and, therefore, are the most appropriate, since they do not require a sudden consumption of energy (glucose), such as: 

    athletics

    cycling

    swimming

    football

    tennis

    Golf

    mountaineering

Likewise, there are also sports that are not advised for the person with diabetes, since the appearance of a possible hypoglycemia, a vascular injury or an accident, can increase their risk.

    Spearfishing

    Motorsport

    parachuting

    boxing

    Martial arts

What are the strategies to avoid hypoglycemia or ketosis during sports practice?

    Perform self-monitoring of blood glucose half an hour before sports practice.

    If it is less than 100mg/dL: take a supplement before exercise, such as fruit, cookies or energy drinks or postpone exercise.

If you are between 100 mg /dL  – 150mg /dL: you can exercise without risk, but always controlling blood glucose.

Perform self-monitoring of ketone bodies if glucose is greater than 250 mg/dL:A. If it is greater than 250 mg /dL: postpone exercise and perform self-control of ketone bodies.

    If it is negative: you can exercise.

    If positive: exercise is discouraged.

If diabetes is uncontrolled (greater than 300  mg/dL or there are ketone bodies in the blood): administer insulin quickly and wait about two hours. Then re-monitor blood glucose and ketone bodies.

    Decrease the dose of insulin before physical exercise, if necessary.

    Give insulin in a place other than the place you are going to exercise (For example, you should not put insulin on your thigh if you are running).

    Avoid physical exercise at the time of the peak of insulin action. (For example, if blood glucose is normal and rapid insulin is injected, avoid the peak of exercise at 1-2 hours.)

    Take a carbohydrate supplement during exercise if it is prolonged (every 30 – 45 minutes).

Do not forget that good hydration is essential.

    Increase food intake (pasta type or slow-absorbing carbohydrates) until 24 hours after activity, depending on duration and intensity, to avoid exercise-induced late hypoglycemia.

    Learn to recognize the sensations of the body itself before the variations in blood glucose caused by exercise.

What is insulin?

Insulin is a hormone secreted by the beta cells  of the  pancreas,mainly in response to the presence of glucose in the blood and, to a lesser extent, other substances contained in food.

The action  of this hormone is fundamental because it is what allows food to be used correctly. It is the  maximum responsible for glucose (and  proteins  and  fats) entering the  cells of peripheral tissues    (such as  muscle,  liver,etc.) where it will beused. Using a  simile  of ordinary life, insulin is the key that allows to open the door (peripheralcells) for food to enter.

Insulin is an essential hormone for life, so there is always a basal secretion  that guarantees  minimum levels of the hormone. These insulin levels increase  after  meals, so that you can take advantage of food. The amount of insulin secreted depends on the type of food (the  more  sugars  we eat, the higher the insulin secretion). 

What are the characteristics and types of insulin?

The insulins available on the market are usually classified according to  the  duration  of  action of each type of insulin (ultrafast,  fast,intermediate and prolonged action), which is called “the insulin curve”. 

Insulin cannot be given   orally because it would be destroyed  in the digestive tract. Itmust therefore be administered by  injection, usually    subcutaneously.

It is possible to administer a single type of insulin or several injections according to the needs of each person.

Insulin that is intended to meet constant needs is often referred to as “basal insulin,” while insulin injected to reduce hyperglycemia spikes is called “bolus.”

It is very important to adjust well the doses  and type of insulin with food intake and exercise, to avoid hypoglycemia and other decompensations.

TYPE OF INSULINbeginningPICOduration
Ultrafast-acting insulins (rapid analogues)10 a 15 minuots1:30 to 2 hours3 to 4 hours
Fast-acting insulin (regular)30 minutes2 to 4 hours6 to 7 hours
Intermediate-acting insulin (NPH)1 to 2 hours6 to 8 hours12 to 16 hours
Slow-acting insulin (basal analogues)1 to 2 hoursNo peak20 to 24 hours
Mixed insulins (Mixtures of different insulins with different portionsThe action curve will depend on the rapid-basal ratio of each mixture 10 a.m. to 4 p.m.
Ultra-slow-acting insulins (insulin degludec) or Long-acting insulins2-3 daysNo peak+42 hours

In relation to the time that should elapse between the injection of insulin and start eating, the general recommendations are those of the attached table, although in some cases it is necessary to customize it. In case of hypoglycemia prior to intake, first of all it is necessary to resolve this and shorten the time frame.

TYPE OF INSULINRECOMMENDED RANGE
NPH45-60 minutes
Fast (Regular)20-30 minutes
Quick Mix – NPH20-30 minutes
Ultrafast analoguesNo waiting
Slow analogsNot related to intake
Mixture of analogues – NPHNo waiting

Insulin conservation

The insulin in use is kept up to one month at room temperature (15-30ºC), away from light and direct heat. If the temperature is higher, it should be stored in cork containers, refrigerators or portable thermoses. Remember that cold insulin injection can be painful. The reserve insulin should be stored in the refrigerator, although if it is frozen it must be discarded. When starting a new container it is advisable to check the expiration date. When traveling, insulin must be part of the hand luggage to avoid problems, among others those derived from the loss of luggage.

Where is insulin injected?

The insulin in use is kept up to one month at room temperature (15-30ºC), away from light and direct heat. If the temperature is higher, it should be stored in cork containers, refrigerators or portable thermoses. Remember that cold insulin injection can be painful. The reserve insulin should be stored in the refrigerator, although if it is frozen it must be discarded. When starting a new container it is advisable to check the expiration date. When traveling, insulin must be part of the hand luggage to avoid problems, among others those derived from the loss of luggage.

The most common places are shown in the drawing and should be used on a rotating basis. It is important to remember that physical exercise in a given area increases the rate of absorption.

Insulin injection techniques

It is recommended the injection perpendicular to the body, with needles between 5 and 8 mm.  In length, tightening the skin. In some cases, however, it may be helpful to pinch your skin and use other needle lengths. The attached drawings shall indicate the best characteristics for each person.

Recommended insulin vial injection procedure

    Wash your hands.

If insulin is cloudy mix until it is uniform. Introduce  into the vial of insulin, the amount of air equivalent to the prescribed dose and a little more.

    Turn around the vial without removing the needle.

    Get some more out of the prescribed insulin.

    Remove the needle from the vial.

    Placing the syringe at eye level, remove air and adjust the dose. Inject.

    Remove the needle without rubbing.

If two types of insulin mixed in the same syringe are used, the technique described above is followed, but air is introduced into both vials. It is important to first load the fast (transparent) insulin, purge and then introduce the slow (cloudy).

Injection procedure with “Pens”

    Wash your hands.

    If the insulin is cloudy, mix until the liquid looks uniform.

    Curly the needle.

    Put the “pen” upright, with the needle up; check that a few drops of insulin come out.

Load the indicated dose. Inject  the insulin and hold down the injection button while counting up to 10 very slowly.

    Remove the needle without rubbing.

    With the large outer cap unsrost the needle and replace it if necessary.

    An appropriate injection technique helps improve diabetes control.

Remember that an appropriate injection technique helps improve diabetes control. Although we must never forget the importance that diet and physical activity has for this control.

Treatment with multiple insulin injection

Unfortunately, classic insulin guidelines often have drawbacks such as requiring rigidity in schedules and often associated with high fasting glucose and/or nocturnal hypoglycemia. The development of new insulins known as insulin analogues, and the improvement of self-analysis systems, have facilitated the progressive spread of this type of treatment.

Multiple insulin injection treatments try to mimic the natural secretion of insulin by combining slow-acting analogues or “insulin to live” and short-acting analogues also called ultrafast or “insulin to eat”. The slow-acting analogues are injected once or twice a day and the ultrafast-acting analogues in each meal and the two cannot be mixed in the same syringe.

Treatment with combined analogues in multiple injection facilitates adaptation to variable schedules, decreases the risk of nocturnal hypoglycemia and usually improves fasting glucose.

For multiple injection treatment to be effective, the

    Frequent self-analysis.

    Proper handling of quantities and types of food.

    Experienced healthcare team.

    Firm commitment between the person with diabetes and the professionals who care for them.

The slow-acting analogue usually constitutes 45-50% of the total dose of insulin (in a single dose or in two separate injections for about 12 hours) and the short-acting analogue the remaining 55-50%, spread over the various meals.

Example: A person who needs 52 a. daily insulin could use 24 a. of long-acting analogue at bedtime and of the short-acting analogue 8 a. at breakfast, 10 a. in the meal and 10 one. at dinner.

Dose adjustment

This is usually done as follows:

Slow-acting analogues

    In the case of slow-acting analogue one injection a day, fasting glucose conditions the dose. It is usually adjusted one at a time or two by two units.

    In the case of slow-acting analogue two injections a day, pre-injection glucose conditions the dose. It is usually adjusted from 1 to 1 units.

Short-acting analogues

    The doses depend on the result of the capillary glycemia prior to each meal and the amounts and type of carbohydrates to be taken.

    The sensitivity index is a good aid to a more effective approach to adjustment.

    The sensitivity index reflects the ability of an insulin unit to modify glucose levels in each person. The sensitivity index is calculated by dividing the figure of 1,800 (fixed) by the total dose of insulin required in 24 hours.

Example: For a total dose 60 units daily Sensitivity index = 1,800/60 = 30 is the range of glycemia that will modify 1 a. insulin or short-acting analogue. Thus, if a person when at 120 mg /dL  of glycemia needs 10 a. of insulin, when it is found: at 90 mg /dL  should be injected 9 a, at 150 mg /dL  11 a, at 180 mg /dL  12 a, etc.

Subcutaneous inffusor: insulin pump

It is a therapeutic resource for the treatment of people who need insulin. It aims to achieve optimal glucose control through a complex system that mimics the secretion from the pancreas of people without diabetes. In this sense it is, with some differences, an alternative to treatment with multiple insulin injection.

It is an external apparatus to the organism consisting of:

    Insulin depot with a precision plunger (a).

    Microprocessor that is given instructions (dose and time), which is battery-powered (b).

    Catheter connecting the pump to the skin (c).

    Subcutaneous insertion cannula (d) that is fastened with adhesive dressing, usually in the abdomen.

    Screen with information (e) that includes alarms that alert about a malfunction of the system (catheter obstruction, low insulin reserve, battery …).

Its size is similar to a cassette tape with a thickness of approximately 2 cm. and weight of about 300 g.

Insulin is given in two modalities:

Continues (basal)

It covers basal insulin needs. It is programmed according to the requirements of each person. It can be constant throughout the day or, if necessary, variable in different periods of day and night.

Complementary doses (or bolleys)

It covers insulin needs due to food intake. The doses are decided by the user based on the result of the glucose self-analysis before each meal and the amount of carbohydrates.

The inffusor is loaded with fast-acting insulins. It can be used permanently or only at night, combined in this case with conventional injections during the day. You can also temporarily disconnect for some activities, such as swimming.

It is important to remember that an inffusor is not an artificial pancreas, as it does not measure capillary glycemia or modify insulin doses on its own.

Advantages

    Flexibility to adapt insulin to diet and exercise modifications.

    More freedom in the organization of daily activities and adaptation to unforeseen situations.

    Decreased frequency and severity of hypoglycemia (night or daytime unnoticed).

    Decreased glucose oscillations throughout the day

    Decrease in the frequency of punctures

Disadvantages

    Possibility of ketoacidosis due to interruption of insulin flow (disconnection or obstruction of the catheter, electronic failure, etc.)

    Local infections at the catheter injection site.

    Aesthetic.

Requirements for its use

In relation to the user, it is necessary that:

    Have a favorable attitude to strict metabolic control and the demands that this entails.

    Overcome the possible fear of dependence on a device.

    Have learning capacity, as knowledge and skills are required for its management.

    Observe the usual hygiene measures on the injection sites, to prevent infections and carefully handle the material.

    Practice a minimum of four capillary blood glucose checks per day.

The health service will offer:

    A multidisciplinary team specifically trained with sufficient dedication to teach the user and their families:

        The operation of the device

        The measurement of carbohydrates from food

        Insulin dose adjustments

    Intensive dedication and support during the trial period prior to the final decision.

    Continuous attention (face-to-face or telephone) 24 hours a day.

    Response to emergency situations, both clinical (decompensation) and technical (material replacement).

Most common indications:

    In pregnancy planning and during pregnancy.

    Severe unnoticed or nocturnal hypoglycemia.

    Difficulty in obtaining good metabolic control with intensive conventional treatment.

    Erratic schedules that make standard treatment difficult.

    High insulin sensitivity (very low needs) in type 1 diabetes.

Limitations

The need to comply with the above-mentioned requirements constitutes a major limitation on the use of inffusors, in addition to other economic requirements. It should be borne in mind that the cost of treatment is, for the time being, more than double that of conventional treatment.

Oral treatment of type 2 diabetes

The goals of diabetes treatment can be summarized in three:

    1. Improve quality of life (especially avoiding hypoglycemia)

    2. Prevent complications

    3. Reduce mortality

What is the initial pharmacological treatment of people with diabetes who do not meet adequate glycemic control criteria with diet and exercise?

If after a period of at least 3-6 months with non-pharmacological measures an adequate glycemic control is not achieved, the initiation of pharmacological treatment should be considered. Hypoglycemic treatments should be prescribed with a trial period and monitor their response, using HbA1c as a measure of effectiveness.

Metformin is recommended as the first oral treatment option for patients with DM 2 in obese and non-obese patients. Although, according to the data sheet, the use of metformin is contraindicated in patients with glomerular filtration rate (GFR) less than 60 ml/min, its use seems safe in patients with glomerular filtration rate between 30-60 ml/min, although between 30-45 ml/min it is recommended to decrease the dose

Sulfonylureas are indicated when metformin is not tolerated or contraindicated. They produce weight gain. Gliclazide  and glimepiride have a lower risk of severe hypoglycemia and are single daily intake, so they are an appropriate choice in the elderly or to facilitate compliance. Glibenclamide has an increased risk of hypoglycemia. Currently its use  is not widespread.

Repaglinide may be an alternative to sulphonylureas in patients with irregular or omitted meals, and in renal impairment.

Pioglitazone is not a drug of first choice. It improves glycemic control (HbA1c), but increases the risk of heart failure, fractures and possibly bladder cancer. It can be used in renal failure.

Inhibitors of DPP-4 (i-DPP-4)(vildagliptin,  sitagliptin,  saxagliptin,  linagliptin,  alogliptin). They improve glycemic control without producing hypoglycemia and have a neutral effect on weight, can be used in renal failure (with GFR 30-60 ml/min), with dose adjustment (not necessary with  linagliptin).

GLP-1 analogues (exenatide, liraglutide,  lixisenatide)are administered  subcutaneously. One of its great advantages is that they help to decrease weight

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