Treatment

The five primary modalities of treatment for diabetes mellitus are the following:

• Diet

• Exercise

• Hypoglycemic agents

• Monitoring

Diet

Nutritional management is the cornerstone of therapy in all types of diabetes mellitus. Since a diet is a part of medical management and should be the first component of management, patients need to be referred early to a registered dietitian for nutritional education and the development of meal plans that are flexible and fitting for their lifestyles.

The current nutritional management for diabetes is to maintain reasonable weight and control blood glucose and lipid levels without compromising health.

Another dietary component that is manipulated is fiber. A high-fiber, high carbohydrate diet has been shown to decrease insulin requirements and cholesterol. Fiber can increase satiety, which might help with weight reduction. It delays gastric emptying and decreases peak blood glucose, so when it is introduced in the diet, blood glucose should be monitored and insulin or any oral agents may need to be restored.

Target Nutritional Goals for Persons with Diabetes 

• Calories- sufficient to achieve and maintain reasonable body weight

• Carbohydrate- Varies in relation to assessment and protein and fat intake; usually 45% to 60% calories. Liberalized individualized emphasis on unrefined carbohydrate with fiber

• Protein – usual dietary intake of protein is double the amount needed. Exact ideal percentage of total calories is unknown; however, usual intake is 12%- 20% of total calories.

• Fat – usually < or = to 30% of total calories, but may be as high as 40%; cholesterol <300mg/day

• Vitamins/Minerals – No evidence that diabetes mellitus influences need

Exercise

In all persons with diabetes, activity is an important part of the medical management and deserves careful and thorough explanation before implementation. Physical activity has important physiologic and psychologic implications. In obese persons, exercise can decrease insulin resistance and help in weight loss. Exercise by persons with diabetes, particularly if they receive insulin or an oral hypoglycemic agent, must consider the dietary plan and medications. Fair to good control should be achieved before starting an exercise program.

Exercise plans for persons with diabetes cannot be discussed without exploring the risks and benefits of such a program.

Benefits and Risks of Exercise for the Person with Diabetes 

Benefits	Risks
Improves insulin sensitivity Lowers blood glucose during and after exercise Improves lipid profile May improve some hypertension Increases energy expenditure; assists with weight loss; preserves lean body mass Increase strength and flexibility	Precipitation of cardiovascular disease, angina, arrhythmias, sudden death Hypoglycemia- exercise related Hyperglycemia after very strenuous exercise Worsening of long term complications

Oral Hypoglycemic Agents

Use in treating persons with NIDDM who are not controlled by diet and exercise alone. These agents are all sulfonylureas which are thought to help control hyperglycemia by:

• Increasing the ability of the islet cells of the pancreas to secrete insulin

• Increasing insulin sensitivity of extrapancreatic tissues

• Decreasing the rate of glucose production by the liver

Monitoring

Self monitoring of blood glucose (SMBG) has been widely accepted as an important tool in the management of diabetes. Functions include:

• To guide physicians in short-term treatment planning

• To guide patients in short term adjustments in insulin and diet

• To signal possible emergency situations

• To enhance patient education and independence