Diet in Diabetes

Aims of dietary management

Achieve good glycaemic control Reduce hyperglycaemia and avoid hypoglycaemia Assist with weight management: - Weight maintenance for type 1 diabetes and non-obese type 2 diabetes -Weight loss for overweight and obese type 2 diabetes Reduce the risk of micro- and macrovascular complications

Ensure adequate nutritional intake

Avoid 'atherogenic' diets or those that aggravate complications, e.g. high protein intake in nephropathy

Medical nutrition therapy (MNT)

is a term used by the ADA to describe the optimal coordination of caloric intake with other aspects of diabetes therapy (insulin, exercise, weight loss). Primary prevention measures of MNT are directed at preventing or delaying the onset of type 2 DM in high-risk individuals (obese or with prediabetes) by promoting weight reduction. Secondary prevention measures of MNT are directed at preventing or delaying diabetes-related complications in diabetic individuals by improving glycemic control. Tertiary prevention measures of MNT are directed at managing diabetes-related complications (cardiovascular disease, nephropathy) in diabetic individuals.

MNT now includes foods with sucrose and seeks to modify other risk factors such as hyperlipidemia and hypertension rather than focusing exclusively on weight loss in individuals with type 2 DM.
The glycemic index is an estimate of the postprandial rise in the blood glucose when a certain amount of that food is consumed. Consumption of foods with a low glycemic index appears to reduce postprandial glucose excursions and improve glycemic control. Reduced calorie and nonnutritive sweeteners are useful. Currently, evidence does not support supplementation of the diet with vitamins, antioxidants (vitamin C and E), or micronutrients (chromium) in patients with diabetes.

The goal of MNT in the individual with type 1 DM is to coordinate and match the caloric intake, both temporally and quantitatively, with the appropriate amount of insulin. MNT in type 1 DM and self-monitoring of blood glucose must be integrated to define the optimal insulin regimen.
The ADA encourages patients and providers to utilize carbohydrate counting or exchange systems to estimate the nutrient content of a meal or snack. Based on the patient's estimate of the carbohydrate content of a meal, an insulin-to-carbohydrate ratio determines the bolus insulin dose for a meal or snack. -minimize the weight gain often associated with intensive diabetes management.

Type I Diabetes in children

Energy:: 1000 kcal for the 1st year
+ 100 Kcal for every year upto 10yrs

*2000 + 50-100 kcal for girls between 12-15 yrs *2000 + 200 kcal for boys between 12-15 yrs
Above 15 yrs 30-35 kcal / kg sedentary 40 kcal / kg moderation 50 kcal / kg very active

 The goals of MNT in type 2 DM should focus on weight loss and address the greatly increased prevalence of cardiovascular risk factors (hypertension, dyslipidemia, obesity) and disease in this population. Hypocaloric diets and modest weight loss (57%) often result in rapid and dramatic glucose lowering in individuals with new-onset type 2 DM.

MNT for type 2 DM should emphasize modest caloric reduction (lowcarbohydrate or low-fat), reduced fat intake, and increased physical activity.

Increased consumption of soluble, dietary fiber may improve glycemic control in individuals with type 2 DM. Weight loss and exercise improve insulin resistance.

Nutritional Recommendations for Adults with Diabetes

Weight loss diet (in prediabetes and type 2 DM) Hypocaloric diet that is low-fat or low-carbohydrate Fat in diet Minimal trans fat consumption Carbohydrate in diet Monitor carbohydrate intake in regards to calories Sucrose-containing foods may be consumed with adjustments in insulin dose Amount of carbohydrate determined by estimating grams of carbohydrate in diet for (type 1 DM) Glycemic index reflects how consumption of a particular food affects the blood glucose

Protein in diet: as part of an optimal diet Other components Non nutrient sweeteners Routine supplements of vitamins, antioxidants, or trace elements not advised

 Recommended composition of diet for people with diabetes Dietary constituent Percentage of energy intake Carbohydrate 45-60% Sucrose Up to 10% Fat (total) < 35% -n-6 Polyunsaturated < 10% -n-3 Polyunsaturated -Eat 1 portion (140 g) oily fish once or twice weekly Monounsaturated 10-20% -Saturated < 10% Protein 10-15% (do not exceed 1 g/kg body weight) Fruit/vegetables 5 portions daily

Gestational Diabetes
Pregnant women need extra 300 kcal and 15g protein during the 2nd or 3rd trimester.
Frequent small meals to be given..

 Diabetic foods and sweeteners Low-calorie and sugar-free drinks useful. many contain sorbitol, are expensive and high in calories, and may cause gastrointestinal sideeffects. not recommended

Salt - reduce sodium intake to no more than 6 g daily.

Algorithm for making a Nutritional care plan

NUTRITIONAL STATUS ASSESSMENT : Weight measure actual weight and height. Calculate Ideal Body Weight (IBW) = (Ht 100) * 0.9 Kg % of IBW = Actual weight / IBW * 100 BMI = wt / ht2 in Kg/m2

CALCULATE THE BMR = Wt * 24 K Cal / day (for men) Wt *22 K Cal / day (for women)

CALCULATE ACTIVITY FACTOR = BMR * Activity level Sedentary = 25 to 30 % Moderately active = 35 to 50 % Strenuous activity = 50 to 100 %

CALCULATE TOTAL ENERGY REEQUIREMENT (MAINTENANCE) = BMR + Activity Factor (in K Cal)

DIVIDE THE CALORIES between Carbohydrates / Proteins / Fats In the ratio of 65 : 15 : 20

PLAN A DIET-discuss diet plan and targets with the patient. Use food exchange list and choose foods preferred by the patient within the calorie limits

DURING FOLLOW UP 1. Encourage the patient 2. Appreciate the efforts taken by the patient recognize the small steps towards achievements 3. Emphasize concomitant exercise plan

Bibliography
Harrisons Internal Medicine 18th edition Davidson 21st edition A practical guide to Diabetes mellitus 5th edition Dept of Endocrinology, CMC Vellore Uptodate.com medscape.com