CHAPTER 15 | Nutritional Aspects of Diabetes 227


Box 15.3 Glucagon-Like Peptide-1 and Gastric Inhibitory Polypeptide Receptor Agonists29-32 Class and drugs


Site, mechanism of action, and administration timing


GLP-1 receptor agonists


Gastrointestinal tract, pancreas, and liver: enhances glucose-dependent insulin release; suppresses postprandial glucagon secretion; increases satiety


Exenatide (Byetta)


Exenatide extended release (Bydureon)


Liraglutide (Victoza)


Semaglutide (Ozempic) Semaglutide, oral (Rybelsus)


Dulaglutide (Trulicity) Lixisenatide (Adlyxin, Lyxumia)


Dual incretin agonist (combines both glucagon-like peptide-1 and gastric inhibitory polypeptide)


Tirzepatide (Mounjaro)


Twice daily Once weekly


Once daily


Once weekly Once daily


Once weekly Once daily


Enhances insulin secretion in response to glucose intake, improves insulin sensitivity, and slows gastric emptying


Once weekly


Nausea, vomiting (especially with high- fat or large meals), weight loss


Side effects


Nausea, vomiting (especially with high- fat or large meals), weight loss, slow gastric emptying, increased satiety


Insulin


If an individual’s target glucose goals are not attained with MNT alone or in combination with glucose- lowering medications, then insulin is required (either alone or in combination with glucose-lowering med- ications).2


listed in Table 15.2.33


Insulin types and their times of action are The transition to insulin often


begins with a long-acting type, such as glargine, detemir, or degludec. Intermediate-acting insulin, such as neutral protamine Hagedorn, was often given at bedtime to control fasting glucose levels, often with a higher risk of hypoglycemia; however, these forms are currently not used as frequently. Medications such as metformin, SGLT2 inhibitors, and GLP-1s are generally continued during the day to control daytime glucose levels. However, many individuals with type 2 diabetes eventually require two or more injections of insulin daily to achieve adequate glycemic control. If large doses of insulin are required, glucose-lowering medications may be combined with the insulin regimen. Circumstances that require insulin in type 2 diabetes include failure


to achieve adequate control with glucose-lowering medications and during periods of acute injury, infection, or surgery.


All individuals with type 1 diabetes require


replacement of insulin that mimics normal insulin action, such as intensive or flexible insulin regimens. (Intensive insulin regimens attempt to mimic the body’s normal pattern of insulin secretion and deliver replacement insulin using the concepts of basal and bolus insulin coverage. Flexible insulin regimes match the insulin dose injected to the amount of carbohydrates consumed in the meal.) Individuals with type 2 diabetes usually do better with these types of regimens as well, but they may require a course that includes both insulin and glucose- lowering medications.29 Regardless of the diabetes pharmacotherapy, older adults should be assessed regularly for hypo- glycemia (blood glucose < 70 mg). Hypoglycemia risk is linked more to treatment strategies than to lower HbA1c levels in individuals with type 2 dia- betes,2


and it may place the older adult at higher risk than hyperglycemia. It is important to ask the


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