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Role of Diet in The Management of Diabetes

In people with diabetes, food is an important part of treatment and diet has long been considered as the cornerstone in the management of diabetes. There are three principles for the treatment of diabetes can be designed as 3Ds - Diet, Drug, Discipline, where diet is the first and foremost principle to be followed by diabetics.

As diabetes is a life long disease, changing of food habits must meet the life style that the diabetic can live with. The word diet control which is generally used in this treatment does not mean eating less or sacrificing favorite foods in life, it means a planned regulated diet that will meet the nutritional needs of the body. The nutritional needs of a diabetic patient will remain same as before the diabetic was detected.

My Pyramid recommended by ADA offers personalized eating plans, interactive tools to help you plan and assess your food choices, and advice to help you:

Make smart choices from every food group.
Find your balance between food and physical activity.
Get the most nutrition out of your calories.
Stay within your daily calorie needs.

A nutritionally well balanced diet is necessary to maintain good health and this is also true for diabetes. The only difference is that a non-diabetic can take any type of food in any time in any amount, that will not cause any immediate problem in his body, but in diabetics the blood glucose level will rapidly be increased. So it is essential to understand the fundamentals of diet in the treatment of diabetes.

The goals of diabetic diets stated by diabetologists are:

To bring down the blood glucose level within normal range and constant maintenance of it to prevent hyper or hypoglycemia and to prevent or delay diabetic complications.
Will meet the nutritional needs of the body by developing meal plan based on the diet history and appropriate patients' life-style to maintain overall health.
To attain and maintain body weight within normal range.
To maintain normal growth rate and subsequent weight in children and adolescents.
To adequate nutrition to meet the increased needs during pregnancy and lactation.

Carbohydrate:

Since 70's recommendation have been made to increase the amount of carbohydrate in diabetic diet without the increase of the total calorie.

Amount and type of carbohydrate:

In poor countries, the carbohydrate intake is 86% of calorie, which is much higher than the upper limit recommended by WHO and is lacking other nutrients also. Diabetics having this type of habit should be encouraged to take other varieties of food keeping the carbohydrate intake within 75% and to ensure in meeting nutrient needs. But diabetics from affluent society may have western type of dietary habits where carbohydrate reduction is not important. So for some people carbohydrate may be 40% of calorie while for others it may be close to 70% of calorie. So diet is to be planned to meet individual needs and life-style.

Because carbohydrates cause blood sugar levels to rise, carbohydrate intake usually needs to be reduced and spread evenly throughout the day. Don’t eat too much carbohydrate at one meal or snack; follow the recommendations of your dietitian or diabetes educator. For patients on low-carbohydrate diets, monitor lipid profiles, renal function, and protein intake (in those with nephropathy), and adjust hypoglycemic therapy as needed. Changes in serum triglyceride and HDL cholesterol were more favorable with the low-carbohydrate diets.

Carbohydrate may be classified in many ways. Slowly absorbed carbohydrates are complex carbohydrates (starch and polysaccharides). The increase of carbohydrate in diet is suggested to come from complex carbohydrate foods. Rapidly absorbed carbohydrates are simple carbohydrates (mono and disaccharides). The use of simple carbohydrate as fruits and milk should be limited because these contain disaccharides and 10-15% of calorie in the form of simple carbohydrate is advocated.

Sucrose

There is a controversy about the use of sucrose in diabetic diet. Since 1987 American Diabetes Association and European Association recommended sucrose in limited amounts in exchange of other carbohydrate (Isocaloric amount). But many diabetologists differ in this opinion of allowing sucrose in diabetic diet. The total amount of carbohydrate in meals and snacks should be more important than the source or the type. Sucrose and sucrose-containing foods must be substituted for other carbohydrates and not simply added to the meal plan. In making such substitutions, the nutrient content of concentrated sweets and sucrose-containing foods, as well as the presence of other nutrients frequently ingested with sucrose such as fat, must be considered.

The role of high fiber diet:

Dietary fiber is the portion of plant foods that is not digested in human intestine. Due to the properties like viscosity, water holding capacity, bile acid binding capacity, microbial degradation fiber forms gel in the gastrointestinal tract to slow the absorption of glucose and lipids, slower stomach emptying, delay intestinal transit time, inhibit intestinal carbohydrate splitting digestive enzyme- decrease the release of gut hormones forms short chain fatty acids. People should eat 25-50 grams of fiber every day. High-fiber foods include oats and barley; whole-grain breads, cereals, and pastas; brown rice, dry beans, peas, and lentils; nuts, fruits, and vegetables.

Fiber is often classified into two categories: Insoluble fiber promotes the movement of material through your digestive system such as; Whole-wheat flour, wheat bran, nuts and many vegetables. Soluble fiber dissolves in water to form a gel-like material. It can help lower blood cholesterol and glucose levels such as; oats, peas, beans, apples, citrus fruits, carrots, barley and psyllium.

Fiber rich diets have been found to improve glucose tolerance, lower total cholesterol, LDL cholesterol and triglycerides, pectins, gums, mucillage, storage polysaccharides hemicelluloses are water soluble fibers found in oats, barley, Ispaghula husk and pulses, some fruits and vegetables. Some of the available data showed that dietary fiber content of whole cereal flour are 8 - 15%, whole pulses are about 32 - 40%, bean are 8 to 10% ground nuts are 9.3%, vegetable of fresh basis may vary from 1.3 to 7.8% and on dry basis from 7.6 to 38.4%, fruits ranges from 1.4 to 3.6% on the fresh basis and 9.6 to 14.4 on dry basis.

Higher intakes of whole grains are associated with protection from CHD, diabetes and, perhaps, obesity. Diabetes associations and national advisory bodies recommend intake of three servings of whole grain foods per day. Find out how much dietary fiber you need and ways to include more high-fiber foods into your daily meals and snacks.

The place of dietary proteins:

There is no controversy in protein requirement for diabetics. Recent recommendation is 0.8 gm/kg of body weight for adults. Protein requirement increases in children, pregnant, lactating women and in certain medical conditions. Protein does not rise blood glucose, as do carbohydrate, rather when protein is added with carbohydrate in a full meal, it delays the rise of blood glucose level, Recommendation have been made for dietary protein for diabetics is 12-20% of the total calorie.

The American Diabetes Association which states, "...the general consensus is to prescribe a protein intake approximately equal to the adult recommended dietary allowance (RDA) of 0.8g/kg body weight per day (~ 10 % of daily calories)...once the GFR begins to fall, further restriction to 0.6g/kg body weight per day may prove useful in slowing decline..."

The quantity and nature of fat:

Evidences showed that high fat diet is related to hyperlipidemia (elevation of lipids in the bloodstream) and many other diseases. Diabetics are associated with those diseases. Recommendations are made to decrease the amount of fat in diabetic diets and these needs to be individualized. Fat present in food delays gastric emptying and slows low carbohydrate absorption. The natures of fats are saturated and unsaturated.

The primary dietary fat goal in persons with diabetes is to limit saturated fat and dietary cholesterol intake. Saturated fat is the principal dietary determinant of plasma LDL cholesterol. Furthermore, persons with diabetes appear to be more sensitive to dietary cholesterol than the general public.

Animal fats are mostly saturated fats; palm and coconut oil are also saturated in nature. Olive and peanut oil are monounsaturated fats and may have little effect on blood lipid levels. Polyunsaturated fats are in vegetable oils, such as corn, sunflower oils; probably lower plasma cholesterol levels. Fat in fish is useful, ecosapentaenoic acid (EPA, omega -3) has been found to have two to five times the ability to lower serum cholesterol levels as do vegetable oils. The current recommendation of total fat in diabetic diet is less than 30% with saturated fat should be less than 10% of the total calorie.

The Food and Drug Administration provides assurance that current fat replacers/substitutes are safe to use in foods. Regular use of foods with fat replacers may help to reduce dietary fat intake (including saturated fat and cholesterol), but may not reduce total energy intake or weight.

Principles of Diet Planning:

Several factors are proposed to be considered in calculating and implementing diet plan.

1. Assessment of desirable body weight and calorie need must be calculated for the patient’s desirable rather than actual body weight.

Calculating desirable body weight by Body Mass Index (BMI):

Body Mass Index (BMI): Weight in kilogram / (Height in meter)*2

Normal Value Of BMI: Men :Kg/m2= 20-25 / Women: Kg/m2 = 19-24

2. Diet is to be formulated on the basis of patient’s age, sex, body weight, physical activity, economic condition, availability of food, personal preference and assessment of present food intake by diet history.

3. Special consideration in diet planning during pregnancy & lactation, change of diet habit in children. In each year to meet the increased need of food to ensure normal growth and development separate diet planning in diseased condition (hyperlipidemia, nephropathy etc.).

4. Estimation and distribution of calorie: The total number of calorie required for the diabetic is more important than the exact proportion of carbohydrate, protein and fat in diet. A lowest number of calories are preferred to maintain desirable body weigh. Distribution of calorie as suggested: 12 - 20% of the total calorie from protein, 50-60% from carbohydrate, 20 -30% from fat (mainly unsaturated fat and less than 10% of the total fat should come from saturated fat).

5. Beside considering other factors, one of the most important part of diet is to reduce weight if the patient is overweight, or to maintain weight if it is normal or to gain weight if it is less than normal.

6. If breakfast is your fast-food meal, choose a plain bagel, toast, or English muffin. Other muffins may be loaded with sugar and fat. Add fruit juice or low-fat or fat-free milk. Order cold cereal with fat-free milk, pancakes without butter, or plain scrambled eggs. Limit bacon and sausage because they are high in fat.

For people with diabetes, ADA recommends an individualized meal -- and lifestyle -- plan as an important aspect of managing diabetes and weight. ADA supports the USDA's effort to emphasize the importance of balancing food intake with daily physical activity. Such a balance is essential in promoting health including the prevention of diabetes and its complications, such as cardiovascular disease. The Diabetes Prevention Program (DPP) proved that type 2 diabetes can be prevented or delayed by keeping weight in control and by increasing physical activity.

Reading labels can help you make wise food choices. Most packaged foods in the grocery store list nutrition information on the package in a section called the Nutrition Facts.