UNIVERSITY 'UNIVERSITY OF FLORENCE
POWER' OF MEDICINE
Master of Science in Human Nutrition Sciences (Class 69 / S)
prof. Edoardo Mannucci, co dr. Matteo Mannucci, Simona Sampirisi thesis.
Thesis 1 year held at the DH Diabetes OU of Geriatrics. Careggi Firenze.
In recent years an increasing number of studies have documented the effectiveness of the "Nutritional Therapy" in the treatment and prevention of chronic diseases - degenerative, of which the most striking example is the diabetes. The study
American Diabetes Control and Complications Trial (DCTT) showed that for the attainment of an acceptable compensation glycometabolic, next to drug therapy and educational proper nutrition is an essential tool that you can not do without. Also among the recommendations of clinical practice for patients with diabetes, the American Diabetes Association published in 2002 nutrition goals play a prominent place.
diabetes remains, therefore, a disease that affects us more closely and for this reason it is should know the causes that can bring home the occurrence and possible nutritional therapies that can be made.
The purpose of this thesis is to focus the non-pharmacological treatment of Type 1 diabetes as it is shown that nutrition education of the diabetic patient is one of the most effective ways to control both blood sugar levels of glycated hemoglobin. The integration made several years ago in the shape of the dietitian in the diabetes team made possible the introduction of a discourse of "generic diabetic diet" is now appropriate to consider the figure of the Nutritionist to replace the dietary approach with 'approach nutrition based on "individual and customized nutrition plans."
In the 3-month training period at the "Hospital Garibaldi" di Catania in the Department of Endocrinology under the leadership of prof.Vigneri R., Prof. L. Frittitta business as a tutor and with the prof. E. Mannucci University as a tutor, I was able to follow in detail some nutritional strategies defined as "Nutritional Therapy" that apply to subjects with diabetes mellitus type 1.
To try to answer the question "Is there a nutritional therapy for type 1 diabetes?" And then determine whether there is a more appropriate method among the possible therapeutic approaches precedentemente descritti, è utile avere un quadro più dettagliato delle condizioni di salute dei pazienti affetti da diabete mellito di tipo 1.
Oltre alle principali variabili demografiche ed antropometriche, esistono numerosi parametri, detti “macro indicatori” che possono essere utilizzati per cercare di caratterizzare una popolazione diabetica, quali ad esempio:
- anamnesi patologica e farmacologica
- Indice di Massa Corporea (IMC), circonferenza della vita
- esami ematici (HbA1c, assetto lipidico, creatininemia, etc.)
- funzione renale (stimata con metodi indiretti quale la clarence della creatinina)
- tipo e dosi di insulina utilizzate
- Pressione arteriosa, etc.
With these parameters you can monitor their glycemic control, drug therapy and drug prescribed, the risk of developing chronic complications of diabetes, identification of any issues that most frequently found in patient populations.
Regarding the possible role of educational therapy to improve the eating habits of subjects with type 1 diabetes, we can identify some of the parameters listed above, as more susceptible to this approach.
For example, the lipid profile, such as glycemic control, certainly suffer hypoglycaemic therapy and cholesterol lowering, but also of exercise and a "diet" is more balanced, providing an appropriate amount of carbohydrates (mostly complex), and input into lipid content (especially saturated).
Another possible area of \u200b\u200binterest to the nutritionist should be the preservation of renal function, by a proper intake of protein. This attention comes from the fact that there are currently no treatments with solid scientific evidence can reduce the risk of incident kidney disease in patients with type 1 diabetes. E 'is known that blood pressure levels higher, a worse glycemic control, as well as a genetic disadvantage may affect renal function. next to these risk factors There is certainly also consider a high-protein diet, which can be tailored nutrition intervention.
As for the achievement and maintenance of body weight "ideal", another field of interest to the nutritionist, we know that usually the type 1 diabetic is a person who has a body mass index below normal or even normal range, and then usually does not require calorie restriction. In this regard, it should be added as often happens the other way: that the diabetic type 1 (similar to that of type 2) naturally tends to reduce the intake of carbohydrates and increase the protein and fat, resulting in deterioration of beta-cell function (already compromised) to the lipotoxicity and renal function for a surplus of jobs as a result of the protein load to "dispose".
These considerations, conceptually valid, but need to find a parallel in clinical practice, primarily through a careful characterization of patients with diabetes mellitus type 1.
The original aim of this work was to study a consecutive series of patients with type 1 diabetes and to follow the time variations of the main anthropometric and laboratory parameters in an attempt to understand whether and what aspects should be implemented in the nutritional care Diabetes mellitus type 1.
the question "Is there a nutritional therapy for type 1 diabetes?", The answer is simply yes, even in light of the results obtained from the analysis of case studies of individuals collected in the last 10 years of diabetes at the DH 'Unit of Geriatrics.
First, one can observe how, despite the fact that diabetes mellitus type 1 is associated with low body weight, a good percentage of people are overweight, perhaps as a consequence of a general and overall worsening of the lifestyle of western populations . Therefore, if one part of the dietary requirements traditionally understood are of little value and indeed potentially harmful in a class of individuals which in itself tends to make a strong caloric restriction (often completely unjustified), especially against the component (in favor of that protein and lipid), a nutritional approach to cognitive-behavioral imprint could have benefits in these patients.
Similar considerations can be made for other cardiovascular risk factors such as hypercholesterolemia el'ipertrigliceridemia, usually in patients with type 1 diabetes mellitus are prone to low values \u200b\u200bof the normal range. From this original work, it is clear, however, a considerable proportion of patients have LDL levels above 130 mg / dl and triglycerides superiori a 150 mg/dl che migliorano solo parzialmente grazie soprattutto al miglioramento del compenso glicemico ed alla terapia ipocolesterolemizzate, che comunque veniva prescritta soltanto ad una piccola proporzione di pazienti. Nonostante ciò, rimane comunque una discreta proporzione di pazienti che dopo 1 anno presentano valori non accettabili o comunque non ottimali di colesterolo LDL e trigliceridi. pertanto, anche in questo caso il nutrizionista potrebbe avere un ruolo importante nell’educazione alimentare e nell’implementazione dell’attività fisica del paziente con diabete di tipo 1.
Inoltre, anche se la terapia del diabete di tipo 1 non può essere che insulinica, è noto da tempo che attività fisica ed una alimentazione equilibrata sono importanti nel mantenimento del compenso glicemico con le più basse dosi di insulina possibili, che mettono a rischio ipoglicemico il paziente, potendo avere effetti negativi sul peso corporeo a lungo termine (per aumento dell’appetito indotto da lievi ipoglicemie) e secondo alcuni autori anche sul rischio cardiovascolare, potendo avere l’insulina un effetto pro-aterogeno.
Infine, come noto dalla letteratura, il paziente diabetico di tipo 1 è a rischio di sviluppare soprattutto le complicanze microvascolari, ovvero quelle maggiormente legate al compenso glicemico e meno agli altri fattori di rischio cardiovascolari, propri invece del diabete mellito di tipo 1 (ipertensione arteriosa, dislipidemia, obesità, etc.). In this study, we tried to study what would be the main predictors of declining renal function, whereas we did not have sufficient data to 1-year retinopathy, the other microvascular complications of diabetes mellitus. The results obtained show how higher levels of blood pressure, HbA1c and LDL cholesterol are among the main independent risk factors for the decline of renal function. Unfortunately, we do not have data on the quantity and quality of food given (by means of food diaries) of the population studied, we can not know whether a high protein diet, as suggested in the literature, is capable of worsening renal function. However, it is possible to hypothesize that a balanced diet, along with tight control glyco-metabolic drug therapy, is a useful defense in the prevention of renal failure and chronic complications of diabetes in general.
groped To get a better grip for type 1 diabetic patient to a healthy lifestyle, there are many strategies that can be taken. There are, in fact, different models of nutritional therapies applicable:
* Counting carbohydrate
* Technical interchanges
* Count of trade in food
* Calculation of grams of carbohydrates
As previously discussed, these models are all related to the identification quantitative and qualitative of carbohydrates in foods, but different in degree of simplicity and accuracy and the applicability of these techniques varies depending on the cultural level and age of the diabetic patient.
nutritional therapy should help optimize glycemic control, especially for the prevention and treatment of microangiopathic complications and the reduction of cardiovascular risk in diabetic patients. The objective of maintaining the "best possible quality of life of the patient must always be considered in any nutritional program and compiling this there must always be adapted to the specific needs of the individual who can also change nel tempo, possono variare a secondo del livello sociale, del lavoro che si svolge ecc..
E’ importante che al fine di aumentare l’adesione alla Terapia Nutrizionale e alle raccomandazioni nutrizionali, è opportuno che venga coinvolta tutta la famiglia del paziente sia perché possano essere da sostegno morale al soggetto affetto da diabete di tipo 1 sia perché queste raccomandazioni possono produrre un tipo di alimentazione tale da permettere un’ottima vita sociale.
E’ opportuno che quando un soggetto diabetico incomincia ad approcciarsi alla Terapia Nutrizionale, questo non venga spaventato con atteggiamenti monitori o con atteggiamenti estremamente restrittivi e condizionanti. E’ importante trasmettere la concezione di Nutrizione come una sana alimentazione importante per la prevenzione delle malattie metaboliche e cardiovascolari che sono complicanze del Diabete mellito.
