Dietarytreatment Fortype 1 Diabetes Mellitus
The dietary recommendations for patients with type 1 diabetes mellitus (DM) do not differ greatly from those for the general population. Dietary advice must be tailored to each individual patient, and certain population groups require special consideration (for example, particular ethnic groups or children). In general, a diet of low fat, high complex carbohydrate, high fiber and low salt intake is recommended. The total fat intake should not exceed 30% of total energy intake, and less than 10% should come from saturated fats. Carbohydrates, predominantly complex carbohydrates, should comprise more than 50% of the total energy intake. Consumption of simple sugars, e.g. sucrose, is acceptable in moderate amounts, as they do not cause acute hyperglycemia (unlike glucose, that does).
Dietary fiber should be increased, ideally to more than 30 g/day, and it is preferable that this be taken in the form of natural soluble fiber as found in legumes, grain cereals or fruit. Protein should comprise approximately 10-15% of total energy intake. Moderate sodium restriction and the national general recommendations for alcohol ingestion should be followed, while 'diabetic foods' and 'diabetic beers' are be~~c. avoided. Regular main meals with between-meal and bedtime snacks remain the usual basis of dietary treatment for type 1 DM patients.
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Insulintreatment Oftype 1 Diabetes Mellitus
The Diabetes Control and Complications Trial (DCCT), published in 1993, established beyond all reasonable doubt that intensive insulin therap y delays the onset and slows the progression of diabetic micro- vascular complications. The achi evement of good blood glucose control while avoiding hypoglycemia is there- fore the therape utic goal for most patients with type 1DM. For the majority of patients this proves to be a major challenge despite considerable input from the diabetic team. Diabetic specialist nurses have assumed a major role in helping patients reach appropriate targets.
A large number of insulin formulations is avail able to treat patients with type 1 DM, many of which have appeared in recent years, and more are in development. Insulin analogs have rightly secured a firm place in the insulin market. It is advisable for the non-specialist clinician to become familiar with the most commonly prescribed insulin formulations and the regimens that are applied in their use. In many countries, such as the UK, insulin delivery via a pen device (insulin pens) has become the most popular method of subcutaneous insulin administration.
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Continuous Subcutaneous Insulin Infusion
Continuous subcutaneous insulin infusion (CSII) attempts to emulate physiological insulin secretion with low basal insulin delivery using a small portable battery- driven pump and a reservoir of short-acting soluble insulin. From the pump, a plastic delivery cannula that ends in a fine-gauge 'butterfly' needle is usually inserted subcutaneously into the ~nterior abdominal wall. The site of implant must be changed every 1-2 days to avoid local inflammation. The basal infusion is supplemented at mealtimes by a prandial boost activated by the patient. The basal
rate and prandial boosts ~re determined according to each individual patient after a brief admis- sion to hospital or by intensive outpatient education. Continuous subcutaneous insulin requires a comprehensive education program prior to its use. The hospi- tals participating in the use of this technique are required to provide a 24-h telephone service so that pump patients can receiye immediate advice. Most patients using this method of treatment achieve excellent control of blood glucose levels.
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Dietarytreatment Fortype 2 Diabetes Mellitus
Diet is the cornerstone of treatment in type 2 DM. Simple initial advice for calorie restriction and avoidance of sweet foods and drinks can lead to symptomatic improvement and a fall in blood glucose levels before any reductions in body weight are detectable. More detailed advice is t4en required to formulate a long- term strategy. The main goal is to correct obesity, as weight .loss will improve blood glucose control, lower blood pressure and lower blood lipid concentrations, all of which may be expected to improve the prognosis for patients with type 2 DM. A diet of low fat, high com- plex carbohydrate, high fiber and low calorie intake is recommended.
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Blood Glucose Monitoring
The ability of the diabetic patient to monitor the effect of their treatment on their blood glucose levels remains one of the major challenges of diabetes care. Exciting new methodologies are now being developed. At present, however, most patients selfmonitor their blood glucose using a wide array of commercially available blood glu- cose meters, which all achieve clinically acceptable stan- dards of accuracy and precision, at least in laboratory conditions. Not all atients (nor indeed nurses and doctors in hospital wards) are able to achieve such stan- dards. This emphasizes the need for adequate instruc- tion in the technique and regular qualitycontrol assessment.
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