Tackling Metabolic Syndrome and Insulin Resistance

TECHNICAL SESSIONS

TACKLING METABOLIC SYNDROME AND INSULIN RESISTANCE

Mrs. Komal Bhambore

CEO- Panacea Health Education

The metabolic syndrome is characterized by a group of metabolic risk factors in one person. They include:
• Abdominal obesity (excessive fat tissue in and around the abdomen)
• Atherogenic dyslipidemia (blood fat disorders — high triglycerides,
low HDL cholesterol and high LDL cholesterol — that foster plaque
buildups in artery walls)
• Elevated blood pressure
• Insulin resistance or glucose intolerance (the body can’t properly
use insulin or blood sugar)
• Prothrombotic state (e.g., high fibrinogen or plasminogen activator
inhibitor–1 in the blood)
• Proinflammatory state (e.g., elevated C-reactive protein in the blood)

People with the metabolic syndrome are at increased risk of coronary heart disease and other diseases related to plaque buildups in artery walls (e.g., stroke and peripheral vascular disease) and type 2 diabetes. The metabolic syndrome has become increasingly common around the globe. The dominant underlying risk factors for this syndrome appear to be abdominal obesity and insulin resistance. Insulin resistance is a generalized metabolic disorder, in which the body can’t use insulin efficiently. This is why the metabolic syndrome is also called the insulin resistance syndrome. Other conditions associated with the syndrome include physical inactivity, aging, hormonal imbalance and genetic predisposition.

Some people are genetically predisposed to insulin resistance. Acquired factors, such as excess body fat and physical inactivity, can elicit insulin resistance and the metabolic syndrome in these people. Most people with insulin resistance have abdominal obesity. The biologic mechanisms at the molecular level between insulin resistance and metabolic risk factors aren’t fully understood and appear to be complex.
Diagnosis:
The American Heart Association and the National Heart, Lung, and Blood Institute recommend that the metabolic syndrome be identified as the presence of three or more of these components:
• Elevated waist circumference:
Men — Equal to or greater than 40 inches (102 cm)
Women — Equal to or greater than 35 inches (88 cm)
• Elevated triglycerides:
Equal to or greater than 150 mg/dL
• Reduced HDL (“good”) cholesterol:
Men — Less than 40 mg/dL
Women — Less than 50 mg/dL
• Elevated blood pressure:
Equal to or greater than 130/85 mm Hg
• Elevated fasting glucose:
Equal to or greater than 100 mg/dL

AHA Recommendation for managing Metabolic Syndrome:
The primary goal of clinical managing metabolic syndrome is to reduce the risk for cardiovascular disease and type 2 diabetes. Then, the first-line therapy is to reduce the major risk factors for cardiovascular disease: stop smoking and reduce LDL cholesterol, blood pressure and glucose levels to the recommended levels. For managing both long- and short-term risk, lifestyle therapies are the first-line interventions to reduce the metabolic risk factors.
These lifestyle interventions include:
• Weight loss to achieve a desirable weight (BMI less than 25 kg/m2).
• Increased physical activity, with a goal of at least 30 minutes of moderate-intensity activity on most days of the week.
• Healthy eating habits that include reduced intake of saturated fat, trans fat and cholesterol.

TYPE OF INSULIN & NUTRITIONAL CARE

Mrs. Swarupa Kakani

Chief Dietitian, Sagar Hospitals, Bangalore

Research Scholar, Home Science Dept, Smt. VHD Central Institute of Home Science, Bangalore University.

Diabetes was a rapidly emerging major public health problem in urban areas of developing countries and proper and correctsteps needed to focus attention on the consequences of improperly treated diabetes. Maintaining a healthy diet is important for everyone, but it is vital for people with diabetes.In a very nutshell, a diabetic diet plan is usually a complete and wholesome eating plan with the proper proportion of carbohydrates, proteins, along with other nutrients meant to make a good, secure and slow release of glucose to the blood. The ultimate target should be to hold the blood glucose degree as near as you can to that of the typical normal human being.

Insulin is a hormone is made by special cells in our pancreas called beta cells, which are located in clumps of cells called islets. After manufacture and release by the beta cell, insulin circulates in the blood, going to all cells and acts with a mechanism that has been compared to a lock and key. On each cell is a "door" that can allow glucose to enter. However, this door stays locked until insulin comes around. Insulin is the key that opens the door. When insulin is present, and the "door is unlocked", glucose can enter the cell and be used as fuel.

Types of Insulin

Insulins are divided into rapid-acting, very rapid-acting, intermediate-acting, and long-acting, based on the number of hours until their "peak" action. Peak action occurs when the concentration of insulin is greatest in the blood, and has its greatest glucose-lowering effect.

The criteria considered in choosing insulin are how soon it starts working (onset)when it works the hardest (peak time)how long it lasts in the body (duration). All people with type 1 diabetes require insulin injections to live, and many type 2 patients end up needing insulin to control their disease. Insulin comes in several different strengths and actions. A rapid acting insulin such as Humalog is injected immediately before a mealand starts working in under fifteen minutes. Its peak action (when it is working the hardest) is between sixty to ninety minutes after injection, about the time when blood sugar levels would be at their height after a meal. Regular insulin starts working thirty to sixty minutes after injection and peaks in three to five hours. NPH insulin is a longer lasting insulin with a slower onset and peak action.

Insulin mixes can also be used to "cover" a meal; the most common premixed insulin is 70/30 (NPH and regular). Newer long acting insulin such as insulin glargine (Lantus) are designed to provide twenty four hour coverage.

Nutritional care:

A diabetic human being have to discover what to try to eat, exercise discipline on just how much to try to eat and when to try to eat as a way to keep his blood sugar degree inside the desired selection. Meal plans must be individualized to accommodate food preferences, cultural influences, physical activity patterns, and family eating patterns and schedules. The meal planning approach selected must assist families to learn the effect of food on blood glucose levels. The system must also be comprehensible and one that can be implemented within the context of the family’s lifestyle and eating patterns. Medical nutrition therapy plays a major role in the management of diabetes particularly in children with type 1 diabetes in children, it is often one of the most difficult aspects of treatment.

Nutrition recommendations for children and adolescents with type 1 diabetes should focus on achieving blood glucose goals without excessive hypoglycemia, lipid and blood pressure goals, and normal growth and development. This can be accomplished through individualized meal planning, flexible insulin regimens and algorithms, SMBG, and education promoting decision-making based on documentation and review of previous results. Children with diabetes often require multiple daily injections of insulin, using combinations of rapid-, short-, intermediate-, or long-acting insulin before meals and at bedtime to maintain optimal blood glucose control. In most centers, the majority of children with diabetes are treated with two or three doses of rapid-acting or short-acting insulin combined with intermediate-acting insulin. However, many patients require more frequent insulin administration in order to achieve and maintain good glycemic control, especially after the honeymoon period is over. Cross-sectional epidemiological studies have been unable to document improved control with increasing numbers of insulin injections per day, indicating that the number of injections alone is not sufficient to achieve optimal glycemic control. However, greater flexibility provided by multiple daily insulin injections (MDIs) per day, combined with carbohydrate counting and dose determined using an insulin-to-carbohydrate ratio, makes this an attractive therapeutic regimen for most middle school and high school students.

There is some evidence that total carbohydrate content of meals and snacks is most important in determining the postprandial glucose response and, thus, in determining the premeal insulin dosage . The Dose Adjustment for Normal Eating (DAFNE) study group documented a decrease in HbA1c and an increase in patient satisfaction in adults after initiating diabetes management using carbohydrate counting for meal and snack carbohydrate content and insulin-to-carbohydrate ratio to determine the insulin dose . Consistency of food intake (carbohydrate) is important for children and adolescents who are on fixed insulin regimens and do not adjust premeal insulin dosages.

Meal Planning

Individualize distribution of carb, protein and fat based on nutrition assessment.

Monitor total amount of carb, more importantly than the source, at the meal or snack.

Provide 3 meals and 1-3 snacks/day as needed based on the age of the patient and usual eating, activity, school and work schedule.

Control protein and fat intake, as well as carb to maintain healthy wt and control blood lipids.

Adherence to a meal plan, a consistent snacking pattern, timely adjustments for hyperglycemia, and appropriate treatment of hypoglycemia are associated with better glucose control.

Medical Nutrition Therapy (MNT)

Assess growth and body mass index related to age, sex and activity level to determine energy needs.

Promote normal growth and development in children and adolescents with adequate nutrition.

Achieve and/or maintain healthy weight in adults.

Teach carbohydrate (carb) counting or carb awareness to match the level of detail the patient can handle.

Choose goal of consistent carb intake for patients on fixed insulin doses or variable carb intake based on insulin to carb ratios for patients on intensive insulin regimens or insulin pump therapy.

Patient can assess blood glucose response to snacks and meals by self monitoring (SMBG).

Patient should adjust carb intake for exercise: Example: add 10-15 grams carb per hour of extra activity or reduce insulin in anticipating activity. Amount of carb required pre-exercise depends on intensity, duration of exercise.

To avoid symptomatic hypoglycemia, patient ingests 15 grams quick-acting carb when blood glucose level is < 70 mg/dl or dropping quickly and rechecks 15-20 minutes later. For children < 5 years of age, provide treatment when blood glucose level is < 100 mg/dl.

Nutrition counseling should be sensitive to the personal needs, willingness to change, and ability to make changes of the individual with pre-diabetes or diabetes.

Goals of MNT that apply to specific situations

For youth with type 1 diabetes, youth with type 2 diabetes, pregnant and lactating women, and older adults with diabetes, to meet the nutritional needs of these unique times in the life cycle.

 For individuals treated with insulin or insulin secretagogues, to provide self-management training for safe conduct of exercise, including the prevention and treatment of hypoglycemia, and diabetes treatment during acute illness.

Clinical trials/outcome studies of MNT have reported decreases in HbA1c (A1C) of ∼1% in type 1 diabetes and 1–2% in type 2 diabetes, depending on the duration of diabetes . Meta-analysis of studies in nondiabetic, free-living subjects and expert committees report that MNT reduces LDL cholesterol by 15–25 mg/dl . After initiation of MNT, improvements were apparent in 3–6 months.

Nutrition for Type 1 Diabetes

The nutrition plan for type 1 diabetes (T1DM) integrates food choices and physical activity with insulin therapy, to achieve normal growth, appropriate body weight, optimal control of blood glucose and other risk factors, while avoiding hypoglycemia.

Base food intake on age, sex, stage of growth, food preferences and usual eating, activity, school and work schedule.

Use food intake guidelines to help achieve and maintain healthy blood glucoses, lipid levels, and blood pressure to prevent, reduce or delay complications.

Provide medical nutrition therapy (MNT) that emphasizes age and developmentally appropriate guidelines.

Patients on intensified insulin regimens count anticipated carb intake, and adjusts fast-acting insulin (Nutritional Dose) based on Insulin:Carb ratio. Example: Determine if patient needs 1 unit (U) per 15g carb (average); 1 U per 10g (less insulin sensitive); or 1 U per 20g (more insulin sensitive).

May use the "Rule of 500": 500 / total daily dose (TDD) = insulin/carb ratio. Example: if TDD is 50 U, 500/50= 1 U per 10 gm carb .

Patients on fixed insulin doses should be taught carb awareness, or size of 15g carb portions, without exact carb counting. In this case, goal is to keep carb portions consistent, meal to meal, and not adjust insulin dose.

In addition to the Nutritional Dose, patients on intensified insulin regimens check blood glucose by SMBG and add Correctional Dose. Example 1 U per 40 mg/dl over 120 mg/dl; 1 U per 50 over 120 (more insulin-sensitive); or 1 U per 30 over 120 mg/dl (less insulin-sensitive).

Can calculate Correctional Dose with the "Rule of 1800": 1800 / total daily dose = Correction ratio. Example: if TDD is 30 U, 1800/30= 1 U per 60 mg/dl over target level.

Target glycemia above-which correctional dose is added varies with the age of the patient and goals for reduction of hypoglycemia.

High fat content in a meal will prolong the absorption of carb, sometimes causing late hyperglycemia.

LIFESTYLE ISSUES AND THE RELATIONSHIP BUILT FOR DIABETES.

-Mr. Ryan Fernando

CEO- QUA Nutrition

If food can be medicine, then it can also be poison. In the olden days, people died from wars and famine. In today's world people die from so-called lifestyle related diseases. This is a unique phenomenon. Why is a person's lifestyle killing them?

Nutrition scientists and medical doctors worldwide are seeing an increased incidence of these lifestyle diseases such as hypertension, stroke, heart disease and diabetes.

Most of these diseases are preventable through actionable healthy choices through your life. They knock on your door when you mistreat your body and when you eat the foods that are not agreeable or foods that are harmful in excess.

Let us understand how certain lifestyle factors can affect the incidences of diabetes in a person.

If a person is too broadly classified the lifestyle factors they can be listed as follows 1. Food 2. Exercise 3. Stress

Food

Healthy eating is a cornerstone of any diabetes management plan. But it's not just what you eat that affects your blood sugar level. How much you eat and when you eat matters, too.

What to do:

Keep to a schedule.Your blood sugar level is highest an hour or two after you eat, and then begins to fall. But this predictable pattern can work to your advantage. You can help lessen the amount of change in your blood sugar levels if you eat at the same time every day, eat several small meals a day or eat healthy snacks at regular times between meals.

Make every meal well-balanced.As much as possible, plan for every meal to have the right mix of starches, fruits and vegetables, proteins, and fats. It's especially important to eat about the same amount of carbohydrates at each meal and snack because they have a big effect on blood sugar levels. Talk to your doctor, nurse or dietitian about the best food choices and appropriate balance.

Eat the right amount of foods.Learn what portion size is appropriate for each type of food. Simplify your meal planning by writing down portions for the foods you eat often. Use measuring cups or a scale to ensure proper portion size.

Coordinate your meals and medication.Too little food in comparison to your diabetes medications — especially insulin — may result in dangerously low blood sugar (hypoglycemia). Too much food may cause your blood sugar level to climb too high (hyperglycemia). Talk to your diabetes health care team about how to best coordinate meal and medication schedules.

Exercise

Physical activity is another important part of your diabetes management plan. When you exercise, your muscles use sugar (glucose) for energy. Regular physical activity also improves your body's response to insulin. These factors work together to lower your blood sugar level. The more strenuous your workout, the longer the effect lasts. But even light activities — such as housework, gardening or being on your feet for extended periods — can lower your blood sugar level.

What to do:

Talk to your doctor about an exercise plan.Ask your doctor about what type of exercise is appropriate for you. If you've been inactive for a long time, your doctor may want to check the condition of your heart and feet before advising you. He or she can recommend the right balance of aerobic and muscle-strengthening exercise.