Introduction
Diabetes is a chronic disease that requires changes that last a
lifetime. The management of diabetes includes medical nutrition therapy (MNT),
medications, exercise, blood glucose monitoring, and self-management
education/behavior modification.
Type 2 diabetes should not be viewed as
a less severe version of type 1 as it is a highly malignant condition with 50%
of affected individuals dying within 10 years of the diagnosis.
A major contributing factor to the development of Type 2 diabetes is
body weight and the incidence of type 2 diabetes begins to rise at a BMI of 23
kg/m2.
The overall goal of diabetes management is to help individuals with
diabetes and their families gain the necessary knowledge, life skills,
resources and support needed to achieve optimal health. This requires a team
effort that includes diabetes health care professionals and the individuals who
must deal with this chronic condition on a daily basis. The dietitian is a key
member of the health care team, who plays an integral role in the
individualization of management strategies for people with diabetes and those
at risk for developing it.
General Principles
In general, nutrition advice for people with
diabetes is the same as that for all people, and follows the principles for
healthy eating:
The optimum healthy choice of food for people with diabetes is the
same for the general population
Enjoy a variety of foods. .
A regular meal pattern based on starchy carbohydrate foods such as
bread, potatoes, rice, and pasta .Choose wholegrain foods where possible.
Replace fried food with grilled or steamed
Emphasize cereals, breads and other whole grain products, vegetables and
fruits.
Choose lower-fat dairy products, leaner meats and foods prepared with
little or no fat. replacing saturated fat with monounsaturated rich fats and
oils
Achieve and maintain a healthy body weight by enjoying regular
physical activity and healthy eating.
General Principles
The goals of medical nutrition therapy
Achieve and maintain optimal blood glucose and lipid levels through
appropriate food choices.
Improve quality of life and overall health.
Empower persons to self-manage their diabetes by providing information
to increase their knowledge and skills.
Teach prevention and treatment of the acute complications of
hypoglycemia, hyperglycemia
The goals of medical nutrition therapy
Provide adequate energy and nutrients for attaining and or maintaining a
reasonable weight for adults and normal growth and development rates for
children and adolescents, and meeting increased needs during pregnancy,
lactation, or recovery from illness (reasonable weight is considered
the weight an individual and health care professional agree upon to be
achievable and maintainable; both short term and long term this weight may be
different than desirable body weight).
Reduction of weight in obese patient to reduce insulin resistance.
Prevent or delay the long-term complications of diabetes such as
retinopathy, nephropathy, and cardiovascular disease (secondary prevention).
Weight management and monitoring glycaemic
conttrol
More than 80% of people diagnosed with type 2 diabetes are
overweight. Weight management in type2
diabetes is important to help to reduce insulin resistance, control blood
glucose levels, and lower the risk of long-term complications. Although
preventing weight gain and/or reducing excess body weight can be very
challenging, it is central to optimizing diabetes care and is a cornerstone in
the dietary management of diabetes.
Monitoring of glycaemic control
Glycosylated hemoglobin (HbA1) should be measured at least annually.
values ≤7% are considered a desirable target for most patients with type 1 and
type2 diabetes, and are associated with a reduced risk of complications.
3. Diet therapy
Energy Intake
- Daily requirements to non-obese diabetic
patient are the same needs of healthy person at the same age, sex, height and
type of effort. Obese Diabetic (type II) must follow a reduced total Kcal by 500
kcal per day.
-
Resting Energy
Expenditure (REE) method:
(Men) = 66.5 + [(wt x 13.75) +
(ht x 5.0) – (age x 6.78)]
(Women) =655.1 + [(wt x 9.56)
+ (ht x 1.85) – (age x 4.68)]
Protein
Typically, protein accounts for approximately 12
to 20% or more of total calories consumed. At present, scientific evidence does
not support either a higher or lower protein intake for the person with
diabetes, and protein intakes in the range of 10 to 20% of daily calories are
recommended (RDA). In the presence of diabetic nephropathy, protein should not
exceed 0.8 g/kg or 10% of total calories.
Protein intake should not go below 0.6 g/kg/day
Fat
Fat intake generally should not exceed
30% of energy. Most importantly, saturated fats, because of their
atherogenic potential, should be held at a maximum of 10% of energy needs.
Polyunsaturates, with their tendency
to lower HDL-cholesterol values and their susceptibility to oxidation, should
also be held under 10%.
monounsaturated, should be at or more 10% ; sources such as: canola or
olive oils.
Cholesterol intake, though less influential
than saturated fats on serum lipid values, should be held under 300 mg/day.
These are consistent with those of the American Heart Association and other
groups.
Fat
If LDL cholesterol level elevated
-Saturated fat 7% of kcal
-Cholesterol < 200 mg daily
FISH OILS (n-3)
evidence showing that fish oils can reduce plasma triglycerides and VLDL
concentrations in the diabetic population, as well as reducing blood pressure.
there are also potential effect of fish oils on LDL cholesterol and
glycaemic control in people with diabetes.
Types of fat
CHO
Carbohydrate depends on the state of the patient's case, food habits and
nutritional goals. CHO should provide 50 to 60% of energy intake. Simple CHO
(not as severely restricted in the past) should make less than 1/3 of total CHO intake. Addressing
a sufficient quantity of carbohydrates is important for all individuals, as
well as for diabetics.
Total carbohydrate – more important than the type of carbohydrate
consumed
Choose foods and beverages with little added sugar or kcaloric
sweeteners
Artificial sweeteners (aspartame, saccharin) used in place of sugar.
Food Sources
Grains, vegetables and fruits are a good source of Carbohydrates, it
also provides us with vitamins, minerals and fiber. And diabetic’s attention for Carbohydrates must be
on total quantity rather than rely on food sources.
Vitamins and Minerals:
There is a need for more conclusive evidence on the benefits of vitamins
and antioxidant nutrients in terms of protection from cardiovascular disease
and general health benefits for the diabetic and non-diabetic population.
Pharmacological doses of supplements are therefore not advised. However,
it is recommended that a diet rich in foods which naturally contain significant
quantities of antioxidants, especially fruit and vegetables, is followed.
When food is balanced for diabetics
there is no need for the
use of vitamins and minerals supplements.
Alcohol use in DM
May use in moderation
Women – 1 drink/day
Men – 2 drinks/day
Should consume food with alcoholic beverages – to avoid hypoglycemia
Interfering with gluconeogenesis in the liver
Excessive alcohol intakes can worsen hyperglycemia – raise triglyceride
levels in some individuals
Abstention recommended with:
Pregnancy
Pancreatitis
Advanced neuropathy
Abnormally high triglyceride levels
Table Salt :
Often diabetic Patients suffer from
hypertension, where the salt plays role in that. Therefore, diabetic patients
are advised not to eat more than 3000 mg of sodium daily. And in the event of
a high blood pressure for patients with
diabetes ,patient must reduce the
proportion of sodium to 2400 mg or less daily. And for patients who suffer from
high blood pressure in addition to the renal failure, reducing the deal to 2000 mg sodium or less
per day.
Fiber:
The intake of an adequate amount of dietary fiber is considered very
important.
the daily fiber requirements for
diabetic patients is similar to the
requirements of healthy people, 20- 30 g
of fiber daily to prevent constipation
and reduce cholesterol and glucose levels.
Insoluble fiber: (cellulose,
hemicelluloses)
Soluble fiber: (gums and pectin)
found in fruits and vegetables is more
beneficial than insoluble fiber in DM, because it decreases the post-prandial
glycaemia and acts favorably on blood lipids.
Micronutrient intakes
Folate supplements during pregnancy – prevent neural tube defects
Calcium supplements to reduce osteoporosis risk in older adults
Chromium supplementation not recommended for persons with DM2
Physical Activity
There is now unequivocal evidence that physically fit people are less
likely to develop Type 2 diabetes and some intervention trials have shown that
encouraging people with impaired glucose tolerance (IGT) to increase their
physical activity significantly reduces their risk of developing diabetes .
This benefit is independent of body mass index (BMI) and there is some
evidence that physical activity has a greater protective effect as BMI
increases . It may be of more importance for people at risk of Type 2 diabetes
to increase their physical fitness rather than concentrate on weight reduction.
Physical Activity
The practice of sport is very important for diabetics. Programme
activities include exercise average of 20-30 minutes of air activities such as
walking and scrambling at least three times a week:
Improves the ability of the body to make use of glucose and increase
insulin sensitivity.
Adjusts the level of lipids in the
blood and helps to increase weight loss.
Reduces the requirements for insulin up of 10
- 20%.
They also improve blood circulation and
stimulate the muscles and give a sense
of vitality and pay the morale of the
patient.
Physical Activity
- Blood glucose levels drop during activity.
- Don’t inject insulin prior to exercise.
- If blood glucose below 100 mg consume carbohydrate
prior to exercising
- During exercise:
.20–30 min of
light/moderate activity should not require extra CHO
.30–60 min of moderate
activity may require an extra 10–20g CHO
.30–60 min of strenuous
activity may require an extra 30–50g CHO
- Remember to consume adequate fluid to
prevent dehydration And Proper footwear.
Nutritional Status Assessment in Diabetic Patients
q Anthropometric measurements recorded:
. Height (m) . Weight (kg)
. BMI (kg/m2) . Waist circumference (cm)
Clinical finding
Laboratory which might include:
. Blood pressure
. Fasting/random blood glucose
(mmol/l)
. HbA1c (%)
. Total, HDL and LDL
cholesterol levels (mmol/l)
. Triglycerides (mmol/l)
and where appropriate indicators of renal function (and liver function).
Meal Planning
To help the patient meals plan better, options include:
exchange lists
carbohydrate counting
Menu approach. (See Sample menu
for a diabetic patient)
Exchange lists
Exchange lists serve as the basis for a meal-planning system recommended
by the ADA. The lists simplify meal planning, help the need for daily
calculations, and ensure a consistent intake.
Sorts foods according to their
proportions of carbohydrate, fat, and protein – each item in the group is
similar in macronutrient and energy content
Exchange lists Table
Carbohydrate counting
Carbohydrate information on food labels has simplified carbohydrate
counting. The system is easier to learn than the exchange lists system, gives
the patient more flexible food choices, and provides a better estimate of how
much the blood glucose level will rise after a meal or snack. Also, if the
patient takes insulin, carbohydrate counting can be helpful in determining
insulin dosages.
Menu approach
In the menu approach, the patient and dietitian collaborate to develop
menus tailored to the patient’s needs and preferences. As the patient desires,
menus may be relatively flexible, dictating specific foods and the amounts that
the patient must eat at specific times.
The menu approach is best for patients who have fairly regimented eating
habits or who want to be told exactly what and how much to eat.
Example
- Gender: female – (non pregnant)
- Age: 45 years
- Height: 170 cm
- Weight: 95 kg
- Diagnosis: DM (type 2)
- Activity level: sedentary
Method 1:
655.1 + [(wt * 9.56) + (ht * 1.85) –
(age * 4.68)] * AF
655.1 + [(65 * 9.56) + (170
* 1.85) – (45 * 4.68)] * AF
655.1 + [(621.4) + (314.5)
– (210.6)] * AF
(655.1 + 725.3) = 1380.4 kcal per
day
Method 2: Add
activity factor
1380.4* 1.2 = 1656.48 = 1650 Kcal per day
CHO = 60 % - 1650
* 0.60 = 990 kcal / 4 gm= 247.5 gm
Protein = 20 % - 1650 * 0.20 =
330 kcal / 4 gm = 82.5gm
Fat = 20% - 1650* 0.60 =
330kcal / 9 gm = 82.5gm
Diabetes in special groups
Nutrition therapy for pregnant women with diabetes and GDM:
is individualized on the basis of the nutrition history, pre-pregnancy
weight, and physical activity levels. Generally, an additional 100 to 300
cal/day is added to the meal plan at the beginning of the second trimester.
Three main meals and 3 snacks are recommended.
Adequate nutrition for mother and fetus, this should meet all the
nutrient requirements of pregnancy through the provision of regular meals that
include a large component of slowly absorbed carbohydrate.
Energy intake that limits unnecessary maternal weight gain
Nutrition therapy for pregnant women with diabetes and GDM
Recommended pregnancy weight gain in women with gestational diabetes :
BMI Weight gain(kg)
<25 10-12.5
25-30 7-11.5
30-34 7
>34 0
Limiting weight gain in pregnancy is controversial but in obese women
with GDM is associated with decrease risk of hypertension, CS, large for
gestational age babies but no increase in risk of preterm delivery or small for
gestational age babies , and Blood sugar level should be monitored regularly
and insulin dose and frequency adjusted to maintain capillary between 4.4-6.1
mmol/l before meals and<8.6mmol/l after meals.
Diabetes
in children and adolescents
The nutrition prescription is based on the nutrition assessment. Newly
diagnosed children often present with weight loss and hunger, and as a result
the initial meal plan must be based on adequate calories to restore and
maintain appropriate body weight. Several formulas can be used to confirm that
a child or adolescent is receiving the minimum number of calories necessary for growth and
development.
Diabetes in children and adolescents
Height and weight should be recorded on growth charts every 3 to 6
months to make sure children are growing normally. If not, the overall diabetes
management needs to be assessed. Caloric needs in children change continuously,
and, therefore, food intake should be evaluated every 3 to 6 months.
Daily eating patterns in children generally require three meals and
three snacks, depending on the length of time between meals and physical
activity level. The purpose of the snacks is to prevent hypoglycemia between
meals.
Estimating Caloric Requirements for Youth
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