Nutrition

Nutritional Aspects of D.M.

Objectives
Good to Know the related definitions, Metabolic Goals in Diabetes management, glycemic index of foods. HAVE to know the goals of medical nutritional therapy for type I&II D.M., MNT for type II.

D.M.: is a metabolic disorder characterized by chronic hyperglycaemia with disturbance of CHO, fat & protein metabolism resulting from defects in insulin secretion, insulin action or both. Diabetes is a major health problem, prevalence 5-6% of USA population, 3% in UK, mainly type II. It is a leading cause of blindness, amputation, R.F., heart attack,& stroke. Nutrition plays a key role in the management of this disease. It can affect long term health & quality of life.


Dietary Management: Diet is the cornerstone of treatment of both types. Dietary modification& selection one of 3 programs; 1-Diet alone, for type 2 2-Diet& oral hypoglycemic agent, for type 2. 3-Diet & insulin, for type1. Same nutritional requirements as non diabetic individual of the same age, sex, ht., activity, with some modification. Nutritional intake should carefully monitored to minimized the load on blood sugar regulation mechanism. Goals : Low in (fat, sugar, &salt), plenty of (fruits, veg.,& starchy) foods.

Medical Nutritional Therapy for D.M.

Is an Integral component for diabetes management & diabetes self management education.It include the system by which nutritional care is provided for diabetic patients & specific life style recommendation.MNT for type1:A meal plan based on individual’s usual food intake.Monitor blood glucose levels & adjust insulin doses for the food eaten, timing of the meals &snacks, & exercise (incr. insulin availability & insulin sensitivity), avoid large variation in blood glucose level, &avoid hypoglycemia.Children do not require caloric limitation (for normal growth & development).

The Goals of Medical Nutritional Therapy:

I- Type 1 D.M.; 1-Provide adequate energy to ensure normal growth & development, integrated with insulin & physical activity. 2-Provide adequate energy & nutrients to pregnant & lactating women. 3-Provide nutritional & psychological needs of an aging individual. 4-Provide self-management education for treatment & prevention of hypoglycemia, acute illnesses, & exercise related blood glucose problems. 5-Eat three regular meals per day, no more than six hours apart. Include small snacks between meals. Timing of the meals with insulin.

6-For risk of diabetes individuals; encourage physical exercise, & facilitate moderate wt. loss or prevent wt. gain. Metabolic Goals in Diabetes Management:
Indicators Goals Fasting blood glucose <115mg/dL 2h postprandial blood glucose <140mg/dL HbA1c <6% B.P. <130/85 Lipids (without CHD) total chol.<200mg/dL, TG<200mg/dL , LDL<130mg/dl, HDL >35mg/dL Lipids (with CHD) total chol.<200mg/dL, TG<200mg/dL , LDL<100mg/dl, HDL >35mg/dL


II-MNT for type 2: must be tailored to individual needs. Young adult should be treated like adult except energy intake must be adequate for normal growth & development without excess wt. gaining. Energy; hypo-caloric diet & wt. reduction usually improve short term glycemic level& long term metabolic control. A moderate caloric restriction (250-500Kcal less than average daily intake calculated by dietary history) will incr. sensitivity to insulin & improve blood glucose levels, moderate wt. loss 5-9kg will reduce hyperglycemia, dyslipidemia, &HT. Exercise incr. caloric expenditure, wt. loss in overweight, decr. TG.,& incr. HDL.


CHO ; 55-60% of total caloric intake, replace simple sugar with starches. Nutritionally adequate meal plan. Spacing of meals & snacks (spread CHO throughout the day). Eat lower glycemic index foods. Glycemic Index (GI): is a scale that ranks foods by how much they raise blood sugar levels. The higher the glycemic index of a food, the more it raises blood sugar levels.

The goal is to include low GI foods in diet; the food GI should be less than 55.Low GI Foods (55 or less) Choose Most OftenWhole grain breads & All-Bran cerealOatmealBrown riceAll beans, peas and lentilsApple, orange, peaches, pears, grapefruits, Sweet potato, tomato juice Carrots, broccoli, cauliflowerSweet corn, popcornDark leafy vegetablesJams – small amountSkim or 1% milk ,Low fat, yogurt

Medium GI Foods (56-69) Choose OccasionallyWhite breadBasmati riceShredded wheat cerealHigh fiber crackersPineappleFruit cocktailsPotatoesBeetsIce cream – vanilla or low sugar

High GI Foods (70+) Choose Less Often Instant mashed potatoes Corn Flakes Rice Krispies Refined cereals Waffles/pancakes Soda crackers, rice crackers French fries Digestive cookies, graham crackers Dried dates, figs Fruit bars Sweetened soft drinks Glucose

High GI eg: White bread

Low GI eg: legumes
Time
Blood glucose level
The glycaemic index is a ranking of foods from 0 to 100 based on their effect on blood glucose levels


Sweeteners: Sucrose & other sweeteners 5% of total caloric intake. Fructose; it cause mild incr. in plasma glucose, & it can metabolize without insulin. It is used as sweetening agent in diabetic diet, but its adverse effect of large intake of fructose will incr. s.cholesterol & LDL ( 2 servings of fruits& 3-5 servings of vegetables).Sugary drinks replaced by sugar-free. Other sweeteners;( substitutes for sucrose, provide sweetness without hyperglycemia): Sorbitol, mannitol, &xylitol produce a lower glycemic response than sucrose & other CHO, supply about 2Kcal/gm. Succharin, aspartame, accsulfame K are used in preparation of dietetic diet with controversy.


Dietary fibers; helpful in prevention & treatment of constipation, provide satiety, reduce insulin resistance, decr. S. lipids &blood glucose levels (less post prandial hyperglycemia), the recommended intake 40gm/d soluble& insoluble form. soluble fibers such as oat bran,& barley are great. Protein; 15% of total caloric intake for adult &20% for children, pregnant & lactating women (animal& vegetable sources).In case of nephropathy should decr. protein intake 10% of total caloric intake (to prevent nutritional deficiency & muscle weakness).Vitamins & minerals; when dietary intake is adequate there is no need for additional vitamin & mineral supplementation.Sodium; same as healthy individual up to 3000mg/d. For diabetic with H.T. ≤2400mg/d. For diabetic with HT. & nephropathy ≤2000mg/d.

Fat: high fat diet have metabolic disadvantages, cause insulin resistance, & impair IC glucose metabolism.Reduction of total fat 20-30%,(a good ratio 1:1:1) ≤7-10% saturated fat 10% PUFA10-15% mono unsaturated cholesterol <300mg/d, (if TG &VLDL are high).Increase physical activity, regular exercise, &new attitude will improve long-term lifestyle.If not improve, oral hypo-glycemic agent &or insulin need to be added.

The Balance of Good Health For a balanced diet have a variety of food from the five groups below, in the portions shown.
Fruit and Vegetables To provide vitamins + antioxidants. No evidence for use of supplements except in special situations.
Bread, other cereals, pasta, rice, potatoes, chapattis Starchy foods. Base meals and snacks on these. Encourage low GI, high fibre foods.

Foods containing fats, oils and sugar Cut down on fatty foods and sugary food. Avoid diabetic foods and nutritive sweeteners.
Image reproduced with the kind permission of the Food Standards Agency
Protein Foods Aim not more than 1g/kg bodyweight. Encourage oily fish 1-2 portions/week.
Advise a decrease in saturated fat. Choose fats high in MUFA, eg: olive oil, rapeseed oil.