Water-insoluble fiber (which includes wheat, bran, and whole grain products) affects mainly the lower gastrointestinal (GI) tract, where it increases fecal bulk, helps to prevent constipation, and may reduce the risk of colon cancer. Water­soluble fiber (which includes guar and pectin) affects the upper GI tract by delaying gastric emptying and increasing the intestinal transport time. It may also lower levels of total cholesterol and LDL cholesterol.Although fiber’s beneficial effect on glucose level control remains unproved, eating 20 to 35 grams of water-insoluble or water-soluble fiber a day does promote evacuation and lower lipid levels. Instruct your patients who are increasing their fiber intake to do so gradually and to drink at least 8 cups of fluid a day to minimize GI discomfort.

A dietitian adapts a nutritional plan for an elderly patient with diabetes based on her special needs caused by aging. For instance, the poor vision that typically accompanies old age can affect a patient’s nutritional status by making it hard for her to read food labels or blood glucose meter results. Also, decreased mobility commonly affects a person’s ability to buy and prepare food. And declining mental status may make it difficult for your patient to plan and prepare meals or even remember to eat (or whether she has eaten).Many older people have limited finances, so they may not purchase a wide variety of fresh foods. They often eat irregularly, skipping meals or eating on a random schedule. A declining sense of taste and poor dentition affect nutrition by making mealtimes seem less pleasurable and more trouble than they’re worth. Other elderly people may have a chronic disease, such as kidney or cardiac disease, that increases the challenge of developing a nutritional plan.

Many elderly people take several drugs at the same time, increasing the risk of food-drug and drug-drug interactions, which may affect appetite, taste, and the ability to digest, absorb, metabolize, and excrete nutrients.

Meals delivered to a patient’s home may improve mealtime regularity and food variety. But as with meals served in long-term care facilities, home-delivered meals may limit the patient’s control over food choices and meal timing. A meal plan that concentrates on eating meals at the same time every day and eating foods that provide good nutrition may be the best way to overcome the obstacles faced by elderly patients.

Usually, transplant patients take immunosuppressive drugs to prevent the transplanted organ from being rejected over the long term or to treat incipient rejection. They may start to take these drugs before surgery and continue throughout the life of the organ. Methylprednisolone and azathioprine are usually administered I.V. during surgery. As kidney function improves, the patient takes cyclosporine. Maintenance immunosuppressive therapy usually combines prednisone, azathioprine, and cyclosporine. Patients receiving tacrolimus have less risk of organ rejection and new-onset Type 1 diabetes.

Base your diet recommendations on treatment goals designed specifically for your patient . Consider the various roles of proteins, carbohydrates, fats, sweeteners, fiber, sodium, and alcohol in your patient’s diet.

Cultural and Ethnic Considerations

Each patient’s cultural and ethnic background strongly influences her food customs, eating rituals, food preparation, and body image. Religion also can affect dietary habits. For example, Hindus are vegetarians, and Orthodox Jews follow kosher dietary laws.

Family traditions may dictate mealtime habits and foods to be eaten or avoided. A patient’s finances, social status, and geographic region affect the type and availability of foods she eats, as well. The health care team performs a thorough nutritional assessment of cultural and ethnic practices and incorporates them into a personalized nutritional plan.

Food Labels

The Food and Drug Administration’s requirements for food labels have made a big difference to patients with diabetes as they shop for food. The information on labels is useful not only for assessing individual products but also for comparing ingredients of similar products and of different brands of the same product.

Show your patient several labels of healthful and less healthful foods. Point out that many imported foods lack nutritional information.

Ingredients on food labels are listed in descending order by weight. Determining total sugar content may take some analysis, however, because different forms can be listed separately. Give your patient a list of sugar’s many names, including sorghum, sucrose, lactose, and maple syrup. Explain that foods labeled dietetic aren’t necessarily sugar-free and that natural doesn’t mean sugar-free. Cane sugar, for example, is natural. Dietetic foods are usually more expensive, and they’re unnecessary for patients who make an effort to choose foods intelligently.

Food labels also list the number of calories, total fat content, and amount of saturated fat per serving. The difference between total fat and saturated fat is the portion that consists of polyunsaturated or monounsaturated fats. The polyunsaturated and monounsaturated fat content should be greater than the saturated fat content. Also listed are levels of cholesterol, sodium, total carbohydrate, fiber, sugar, and protein.

A food label promising no cholesterol can be misleading. Vegetable oils containing no cholesterol, for example, may be high in saturated fats. Also, teach your patient to scrutinize labels claiming that a food is a certain percentage fat free. A product that is 75% fat free contains 25% fat by weight-and even more than 25% of the total calories may come from fat. The total calories from fat, listed next to the total calories on the label, will give your patient a clearer picture of fat content. Teach her to carefully read labels boasting fewer calories, light, or lite.

Besides ingredients, food labels now list details of nutritional content. This information makes it easier for your patient to choose foods in accordance with her treatment goals.

The information on the food label is based on the serving size, which appears at the top of the food label. Make sure your patient understands that the nutritional content of the entire package isn’t being described unless the label states that the container has only one serving. The percent of daily value listed on the label is based on a 2,000-calorie diet; teach patients with a different calorie plan to take this into consideration.

Carbohydrates supply the body’s primary source of energy. The brain and red blood cells use only glucose, the building block of carbohydrates. The American Diabetes Association recommends determining your patient’s protein requirements, using the recommended dietary allowance of 0.8 g/kg of body weight for adults, before determining the desired amount of carbohydrates and fat. Also, use your patient’s treatment goals, habits, and blood glucose and lipid goals as guides.When your patient chooses which carbohydrates to consume, instruct her to focus on the glycemic value of a carbohydrate rather than on the type of carbohydrate, such as simple or complex. The glycemic index, created in 1981, provides average glycemic values of certain foods. It can help you predict the rise in blood glucose after your patient has eaten certain carbohydrates. Foods that raise blood glucose levels quickly have a high glycemic value. These include white bread, some cereals, glucose, and root vegetables, such as carrots and potatoes. Foods with a low glycemic value include nuts, legumes, dairy products, fructose, and raw fruits.

Advise your patient to use the index as a guide and to monitor her blood glucose levels after she eats certain foods. Make it clear, however, that the glycemic value of a food is not equivalent to its nutritional value. Although sucrose has a lower glycemic value than a potato, for example, it provides far less nutritional value. And inform your patient that the glycemic value of a food can rise or fall depending on many factors, including the ripeness of the food, the preparation of the food, and the other foods eaten at the same meal.

If your patient is using regular insulin, she can count grams of carbohydrates to help her make food choices. Instruct her to count the total number of grams of carbohydrate in a meal she’s planning to eat. She should then compare that number to the amount of carbohydrate recommended for that particular meal in her meal plan. If she’s consuming more than is recommended, she can increase her regular insulin dose by 1 unit for every additional 10 grams of carbohydrate. If she’s consuming fewer carbohydrates than is recommended, she can decrease her insulin by 1 unit for every 10 grams less.

Instruct your patient to count grams of carbohydrates by consulting food labels, exchange lists, and carbohydrate-counting books. Counting grams of carbohydrate allows for more accurate insulin dosing and more flexible meal scheduling. It also reduces the number of hypoglycemic and hyperglycemic episodes.

When caring for a patient after a kidney and pancreas transplant, repeatedly assess the function of both organs. Assess your patient for hypovolemia and dehydration, which may damage the kidney tubules and increase the risk of thrombosis of the pancreatic vessels. Monitor the patient’s intake and out­put, vital signs, skin turgor, blood urea nitrogen (BUN) level, creatinine level, and hematocrit. Elevated BUN and creatinine levels may indicate kidney dysfunction and rejection. A steadily declining hematocrit may reflect bleeding.

For the first 24 hours after surgery, adjust I.V. fluids every hour in response to your patient’s urine and nasogastric (NG) output. If she has an indwelling urinary catheter, you can monitor urine output accurately. The catheter also decompresses the bladder, allowing the suture line within to heal. After the NG tube and urinary catheter are removed, continue to monitor your patient’s intake and output.

Monitor blood glucose levels every 30 minutes to 1 hour for the first 24 hours after surgery and administer insulin or fluids containing dextrose as necessary. A patient may require insulin for 1 to 2 days after surgery because the function of the transplanted pancreas may be delayed. She may also require insulin if she’s receiving steroid therapy.

Review your patient’s daily laboratory test results, including electrolytes, complete blood count, hemoglobin level, and serum and urine amylase measurements. Collect urine specimens for cumulative amylase determinations taken at 12-hour or 24-hour intervals. Assess insulin, glucagon, and human C peptide levels three or four times per week. Pancreas scans and ultrasound examinations may be performed on the first day after surgery, then once a week until discharge. Ultrasounds examine the function of the new organs and enable the physician to determine the size of the graft and the patency of the veins.

Check your diabetes patient’s abdominal dressing and incision for blood and urinary drainage and for signs of infection. To decrease postoperative complications, have your patient sit on the side of her bed within 24 hours of surgery. She can begin sitting in a chair and taking short walks the day after surgery. Encourage her to cough, breathe deeply, and change positions frequently.

Acarbose, an Intestinal Alpha-Glucosidase Inhibitor, decreases postprandial hyperglycemia by inhibiting the digestion and absorption of carbohydrates. It achieves this by inhibiting the enzymes responsible for the digestion of starches and other carbohydrates in the brush border of the small intestine.The peak action of acarbose occurs within 1 hour of ingestion. The drug is metabolized by intestinal bacteria and digestive enzymes. Because the half-life for acarbose is only about 2 hours, the drug should be taken three times a day.

A physician will begin acarbose therapy at 25 mg three times a day. She will adjust dosages every 4 to 8 weeks based on 1-hour postprandial blood glucose levels and on tolerance until an effective dose is achieved. The maximum recommended dosage is 50 mg three times a day for patients who weigh 60 kg or less. For those who weigh more than 60 kg, the maximum dosage is 100 mg three times a day.

Indications and Contraindications

Acarbose is used with stable Type 2 patients as an adjunct to diet and exercise to reduce blood glucose levels. This drug benefits patients who can’t achieve near-normal blood glucose levels with sulfonylureas or metformin.

Because acarbose increases gas formation in the intestine, it’s contraindicated for anyone with inflammatory bowel disease, ulcerations of the colon, or intestinal obstruction. The drug is also contraindicated for patients with chronic intestinal diseases that alter digestion or absorption. Acarbose is contraindicated during pregnancy or breast-feeding. Patients with kidney dysfunction, DKA, or a hypersensitivity to the drug also shouldn’t take it.

Adverse Effects and Interactions

The most common reactions to acarbose are GI signs and symptoms. Patients may complain of abdominal pain, diarrhea, and flatulence caused by undigested carbohydrates in the intestines. These signs and symptoms tend to subside with time. At doses of 100 mg, acarbose may cause an asymptomatic, reversible increase in serum transaminase levels, especially in women.

The action of acarbose decreases with the concurrent use of charcoal, an intestinal adsorbent, and digestive enzyme preparations that contain carbohydrate-splitting enzymes, such as amylase and pancreatin. Hyperglycemia may result if a patient takes acarbose with thiazide and other diuretic drugs, beta-blockers, corticosteroids, phenothiazines, thyroid preparations, estrogens, oral contraceptives, phenytoin, nicotinic acid, sympathomimetics, calcium channel blockers, or isoniazid. Acarbose can be taken with a sulfonylurea or insulin, but these combinations may cause hypoglycemia. However, acarbose can help to prevent weight gain associated with sulfonylurea therapy.

Advise your patients to take acarbose with meals. Because the goal is to prevent the absorption of intestinal glucose, they should take the drug along with the first bite of food. No food interactions occur.

Many people with diabetes aren’t physically fit, lead sedentary lives, and have microvascular, macrovascular, or neuropathic complications. However, they can still benefit from exercise that’s modified for their needs.If your patient has peripheral vascular disease, an assessment of arterial circulation is essential. Her exercise regimen may be modified to include interval training, such as walking with frequent rest periods. If your patient has only limited use of her legs because of claudication, chair or upper body exercise is a good alternative.

Your patient with retinopathy should avoid isotonic exercises, which provoke straining and cause blood pressure to rise rapidly, either of which can precipitate a hemorrhage of the vitreous humor. For this patient, aerobic exercises shouldn’t jar her head or require a headdown position.

Patients with nephropathy and those receiving hemodialysis tend to have low hemoglobin levels and hematocrit and impaired cardiac function. All these conditions contribute to an extremely low capacity for exercise. These patients should begin exercising slowly for short periods and increase gradually. In patients with renal osteodystrophy, weight-bearing exercise may improve bone density.

Although exercise can’t reverse sensorimotor neuropathy, it can improve the effects of disuse. Because patients with sensorimotor neuropathy have decreased sensation, they should perform stretching exercises gently and avoid highimpact exercises. Instead, they should use low-impact exercises such as walking, bicycling and swimming. Range-of-motion exercises can prevent or minimize joint contractures. Because of her decreased sensation, instruct your patient to inspect her feet daily for blisters, redness, fissures and ulcerations.

Patients with autonomic neuropathy and those taking beta-blockers may have an impaired counterregulatory response that fixes the heart rate at 80 to 90 beats per minute even when they’re exercising. The result is limited exercise tolerance. Exlain to your patient that sudden death or a silent myocardial infarction can occur when her heart fails to respond to nerve impulses. If your patient with autonomic neuropathy doesn’t have a fixed heart rate, her target heart rate should start low and then gradually increase over several exercise sessions. Advise her to avoid sudden changes in body position and significant changes in heart rate and blood pressure.

When a person with diabetes and heart failure takes a sulfonylurea, her body may release antidiuretic hormone-and the resulting water retention and hyponatremia can spell danger.If you’re caring for such a patient, watch for signs and symptoms of the syndrome of in -

• Appropriate antidiuretic hormone
• Weight gain despite anorexia
• Nausea and vomiting
• Muscle weakness
• restlessness
• Possibly seizures and coma.

If you note these signs and symptoms, begin emergency treatment as prescribed to increase sodium levels and prevent central nervous system injury and death. If the patient experiences hyponatremia associated with increased blood volume, a physician will prescribe normal or hypertonic saline solution and furosemide to induce the excretion of more dilute urine.

All patients with Type 1 diabetes must use insulin. Because the insulin dose is determined by blood glucose levels, you and your patient must monitor those levels with particular care.People with Type 2 diabetes produce some insulin, but generally not enough to lower their blood glucose levels. If other treatments can’t control their blood glucose levels, they may also require insulin. Some patients with Type 2 diabetes may require insulin only temporarily during times of stress.

All insulins are administered subcutaneously. Regular insulin may be administered I.V. Because of its protein nature, insulin must be administered by injection. Given orally, it would be digested and destroyed in the GI tract.

Insulin restores the cells’ ability to use glucose as a source of energy, but researchers don’t know exactly how. Insulin is involved in cell membrane transport, so it increases cell growth and the metabolism of carbohydrates, proteins, and fats.

Insulin maintains blood glucose levels through several mechanisms. In the liver, insulin decreases the breakdown of glycogen, prevents the formation of new sources of glucose from amino acids, and prevents the formation of ketone bodies. At the same time, insulin increases the synthesis and storage of glycogen and fatty acids and decreases the breakdown of fat in adipose tissue. Insulin also enhances the use of amino acids and decreases the breakdown of protein in muscle tissue.

Types of Insulin

Insulin is classified as rapid-acting, intermediate­acting, or long-acting, depending on its onset, peak, and duration of activity .

Most rapid-acting insulins begin working in 30 minutes and reach their peak in 2 to 5 hours. Their duration of action is 6 to 8 hours. One form of rapid-acting insulin, lispro, begins working in 5 to 15 minutes and reaches its peak in 30 to 90 minutes. Its duration of action is 2 to 4 hours. Rapid-acting insulins compensate for the meals eaten after injection. For some patients, using lispro before a meal improves postprandial glycemic control and reduces the risk of hypoglycemia because of its short duration of action. Other rapid-acting insulins include regular and Semilente insulin.

Intermediate-acting insulin starts working in 1 to 3 hours and reaches its peak in 4 to 15 hours. Its duration of action is 18 to 24 hours. It may be given in split doses, before meals, but the patient must eat at the time of peak action to prevent hypoglycemia. Intermediate-acting insulins include neutral protamine Hagedorn (NPH) and Lente insulins. NPH insulin contains protamine sulfate, a protein derived from fish that can cause an allergic reaction. Lente insulin is a good choice for people sensitive to protamine.

Long-acting insulin starts to work in 4 to 6 hours and reaches its peak in 8 to 20 hours. Its duration of action is 24 to 28 hours. Ultralente, the only long-acting insulin, gives patients a consistent insulin effect.

Some patients need a mixture of insulins. One that’s rapid-acting, such as regular insulin, for a fast onset and one that’s intermediate-acting, such as NPH, for a longer duration of action. These insulin mixtures are available in premixed bottles. For example, NPH and regular insulin are available in 70/30 and 50/50 mixtures. The premixed bottles are especially useful for elderly patients or patients with vision loss.

Sources of Insulin

Extracts of beef and pork pancreas were once the only sources of insulin. Beef insulin is no longer used, except in some beef and pork mixtures, and pork insulin is rarely used. Today, human insulin, which is derived from recombinant deoxyribonucleic acid technology, and the human analog lispro are the two forms most commonly used. Insulin from all sources appears to be equally effective at controlling blood glucose levels. However, human insulin causes less lipoatrophy, less antibody production, and fewer allergic reactions. And it’s absorbed faster than pork insulins.

Changing between pork and human sources of insulin can disrupt blood glucose levels and require dosage adjustments. People who need insulin only temporarily-a patient with Type 2 diabetes undergoing surgery, for example-should use human insulin.

Indications and Contraindications

Insulin is essential for everyone with Type 1 diabetes. Type 2 patients may need it if diet, exercise, weight control, and oral antidiabetic drugs haven’t been effective. They may also need it during periods of stress involving fever, severe trauma, infection, major surgery, DKA, and HHNK syndrome. Insulin therapy is recommended for women with gestational diabetes if diet alone doesn’t control blood glucose levels.

Adverse Effects and Interactions

Hypoglycemia is the most common adverse effect of insulin therapy. Other adverse effects include lipodystrophy, insulin resistance, and, in rare cases,insulin allergy.

The two types of lipodystrophy are lipoatrophy and lipohypertrophy. Lipoatrophy, which is caused by animal insulins, results from the breakdown of adipose tissue at the injection site or in areas away from the injection site and causes a loss of fatty tissue. Dimpling may result from an injection with an impure insulin preparation or may be an immune response. Treatment includes injecting human insulin or steroids around the area of breakdown.

Lipohypertrophy occurs after repeated injections into the same site. The skin in the hypertrophied area eventually loses sensation. Because the hypertrophied area is an accumulation of fatty tissue, tell your patient not to use it for additional injections because the insulin will be absorbed erratically.

Insulin resistance results from the formation of antibodies that bind to insulin, making it inactive. Patients with cirrhosis of the liver or a disease of the endocrine glands may also develop insulin resistance. The patient becomes unresponsive to usual doses and may need as much as several hundred units of insulin a day. Changing from animal to human insulin or purified pork insulin may correct the problem. Or a corticosteroid may treat it. For obese patients who have nonimmunologic insulin resistance, the treatment is weight loss.

A patient with an insulin allergy may develop redness, swelling, aching, and pruritus at the injection site 4 to 8 hours after the injection. Or she may develop systemic allergic reactions.

Insulin products derived from animal sources cause allergies in some patients. The physician will probably substitute human insulin.

Some people are allergic to the insulin preparations or to the preservatives in the solution. Other people may be hypersensitive to the skin­cleansing agent used before injectionShould . Some patients are allergic to the latex in the stopper of the vial or in the plunger of the syringe. If any allergic reactions occur, your patient should contact her physician immediately.

Systemic allergic reactions to insulin are uncommon, especially with purified insulin preparations. If an anaphylactic reaction occurs, however, it may be life threatening. The signs and symptoms include rash, shortness of breath, tachycar­dia, hypotension, diaphoresis, angioedema, and anaphylaxis. Patients with severe systemic reactions should have a skin test before they begin using a new insulin preparation.

Several drugs can increase or decrease the action of insulin . No foods interact with insulin. However, to achieve optimal glycemic control, patients should follow their prescribed meal plan in conjunction with their insulin prescription.

Administration

The dosage and number of daily insulin injections depend on each patient’s circumstances. Many patients are on an insulin regimen that requires different kinds or mixes of insulin. The physician considers the time of insulin administration, diet, and exercise when determining dosages. After initial insulin dosages have been determined, monitor the effects of the insulin.

Your patient will inject insulin subcutaneously with a short (1/2 inch), small-bore (27, 28, or 29 gauge) needle .

The rate of absorption of insulins other than lispro varies with the injection site. Insulin is absorbed from the abdomen faster than from any other site. The upper arm provides the next most rapid absorption, followed by the thigh and but­tock. Instruct your patient not to administer insulin within a 2-inch radius of the umbilicus to prevent injection into a blood vessel. Because the rate of absorption of insulin changes with the injection site, patients should rotate injection sites within one area, such as the abdomen, before moving to another, such as the upper arm.

Body temperature also affects absorption. Increased blood flow from sitting in a sauna, having a fever, or exercising a muscle causes insulin to be absorbed more quickly than usual.

Storage: Tell your patient that she can keep unopened bottles of insulin in the refrigerator for up to 3 months. She shouldn’t freeze the insulin because freezing can cause clumping. A bottle in current use can be stored at room temperature, out of direct sunlight and extreme heat, for up to 1 month. Prefilled syringes may be stored in the refrigerator vertically (needle up) for 1 to 2 weeks. Instruct her to check the expiration date on the insulin bottle periodically and to discard the insulin when it expires.

Injection: When teaching your patient how to inject insulin, first instruct her to roll the bottle of insulin suspension gently between her hands so that the contents don’t form bubbles or foam. If a bottle of insulin contains granules or clumps after mixing, instruct her to discard the bottle. Because regular insulin is clear, the bottle doesn’t have to be rolled before use. Instruct your patient to discard the bottle of regular insulin if it’s discolored or cloudy or contains granular material.

Next, instruct your patient to stretch the skin at the injection site and insert the needle at a 90­degree angle .

Several new alternatives to syringes simplify insulin injection. Spring-operated insulin pens,which metal container with a are preloaded with bottles of insulin, are convenient and accurate. The cartridges, which don’t have to be refrigerated, supply enough insulin for 3 to 5 days. Using the pen, however, requires skill and dexterity. Patients with impaired vision can buy devices that facilitate drawing up and administering insulin with a syringe, including syringe magnifiers, needle guides, bottle stabilizers, and nonvisual insulin measurement systems.

Disposal: Advise your patient to dispose of needles and lancets in a hard plastic container, such as an empty detergent bottle, or a tightly secured lid. If the patient uses coffee cans to dispose of needles, caution her to reinforce the plastic lid with several layers of duct tape. Some drugstores sell commercial containers like the ones used in hospitals.

Tell your patient to put needle containers in the regular trashnever with recyclables. If she lives in an area with a depot system for dropping off used syringes, encourage her to do that.

Insulin Pumps: Instead of using subcutaneous injections, some patients can use insulin-pump therapy, a method of insulin administration that more closely mimics the normal function of the pancreas. To be a candidate for the insulin pump, a patient must have Type 1 diabetes, be able to monitor her own blood glucose levels, and be able to operate the pump. Patients using pump therapy also must be highly motivated; they’ll have to monitor their blood glucose levels at least four times a day and keep careful records to help evaluate their therapy.

The battery-powered pump contains a syringe and a computer chip that stores information for insulin administration. To administer insulin, the patient attaches an infusion set with a small catheter to the pump. She then inserts the catheter into her abdomen, arm, or thigh. She can wear the pump 24 hours a day but should change the injection site every 72 hours. She should also change the site when it becomes inflamed or painful, or whenever the system leaks or becomes clogged.

Using the pump provides several benefits. Because blood glucose levels can be more tightly controlled, glycosylated hemoglobin levels and the number of hyperglycemic episodes can be reduced. The pump may also help lower the number of congenital birth defects in children who are born to mothers with diabetes. Insulin-pump therapy also may help delay the progression of microvascular and macrovascular complications and neuropathy.