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Wellness & Preventive care
Dietary Management of Diabetes Mellitus
Dr Kasturi Sen Ray
Diabetes is a major health problem being faced by modern society
of today all over the world and India is predicted to have the most number of
people with diabetes mellitus by the year 2025. This disease is the most common
cause of blindness and is responsible for 25 per cent of all new end-stage renal
diseases each year. Once one has developed diabetes, it cannot be cured but
fortunately enough, can be managed very well and quality of life can be improved
under 'Wellness program' involving diet, exercise and medicine.
Diabetes is a metabolic disorder characterised by the limited ability or complete
inability of the tissue to utilise carbohydrate (also known as CHO, since it
is made up of carbon, hydrogen and oxygen), accompanied by changes in metabolism
of fat, protein, water and electrolytes.
Diabetes May Result From:
- Destruction of beta cells
- Defective synthesis of insulin
- Defective release of insulin by beta cells
- Autoimmune disease
- Cellular insensitivity to insulin
These factors ultimately lead to insulin insufficiency within the cells resulting
in inability to utilise glucose as a source of energy.
Long term effect of metabolic derangement may lead to permanent and irreversible
functional and structural changes in the vascular system of the body characteristically
affecting the eye, kidney and nervous system.
Diabetes mellitus is categorised mainly into type I and type II diabetes. Type
I diabetes may be due to autoimmune destruction of pancreatic beta cells in
genetically susceptible persons. Environmental factors including viruses, faulty
diet, bacteria and chemicals may be responsible for the cellular destruction.
They are insulin dependent, usually appears in youth or young adults and therefore
also known as juvenile diabetes. The symptoms appear suddenly and the patient
needs insulin for control. Type II diabetes is often diagnosed in adults and
is known as maturity onset diabetes (common in Indian population). It is characterised
by insulin resistance at the cellular level as the number of insulin receptors
of the cell membrane decreases in both hepatic and muscle tissue, along with
the increase in basal insulin level. There is also gestational diabetes which
is transitional but definitely indicates that the subject is unable to maintain
the sugar level under stress of pregnancy and therefore prone to develop diabetes
in later stages of life.
Different types of diabetes may have different etiology and pathophysiology,
but whatever the underlying cause, the resultant effect is high blood sugar
level (hyperglycemia) and associated problems. Therefore, dietary guidelines
are similar for all the conditions with specific emphasis on Type I and gestational
diabetes where growth of the young or foetus has to be considered.
The Basic Objective of Meal Planning Is-
- To achieve and maintain healthy and productive life
- To maintain optimal nutrition for adequate growth,
development and maintenance.
- To maintain near normal blood sugar level
- To achieve and maintain a desirable body weight
- To provide relief from symptoms
- To prevent, delay or minimise the onset of chronic
degenerative complications.
You can catch diabetes from someone else.
No. Diabetes may run in the family due to genetic factors, particularly
in Type II diabetes, but definitely diabetes is not contagious. Lifestyle
factors also play a major role.
People with diabetes can't eat sweets or chocolate.
If eaten as part of a total calorie requirement, and combined with exercise,
sweets and desserts can be eaten by people with diabetes. They are no
more 'off limits' to people with diabetes, than they are to people without
diabetes.
Eating too much sugar causes diabetes.
No. In fact it works the other way. Diabetes affects sugar level.
Restricting sugar intake may protect a normal
person from diabetes in the future.
No. Restricting total calorie can protect a normal person from being overweight.
Being overweight does increase the risk for developing type II diabetes.
If you have a history of diabetes in your family, eating a healthy meal
plan and regular exercise are recommended to manage your weight.
People with diabetes should eat special diabetic
foods.
A healthy meal plan for people with diabetes is the same as that for everyone
- low in fat (especially saturated and trans fat), moderate in salt and
sugar, with meals based on whole grain foods, vegetables and fruit.
If you have diabetes, you should only eat small
amounts of starchy foods, but no sweet food.
Starchy foods are part of a healthy meal plan. What is important is the
portion size. Whole grain breads, cereals, rice and starchy vegetables
like potatoes, peas and corn can be included in your meals and snacks.
The key is portions. For most people with diabetes, having three-four
servings of carbohydrate-containing foods is about right. Whole grain
starchy foods are also a good source of fiber, which helps keep your gut
healthy.
Insulin causes atherosclerosis (hardening of
the arteries) and high blood pressure and weight gain
No, insulin does not cause atherosclerosis. If calorie and insulin is
given in calculated proportion in relation to the activity level, there
will be no weight gain. It is the life saving measure for insulin dependent
diabetics.
If there is special occasion, one can fast during
the day and have all good foods during the event and still maintain the
total calorie intake
No, fasting and feasting gives extra stress on the glucose homeostasis
mechanism and is bad for a person with compromised glucose tolerance like
diabetics.
Fruit is a healthy food. Therefore, it is ok
to eat as much of it as you wish.
Fruit is a healthy food. It contains fiber and lots of vitamins and minerals
and needs to be included in your meal plan. But because fruit contains
free sugar, quantity per serving should not be unlimited.
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Dietary Management
- Energy requirement should be assessed according
to the subject's ideal body weight, current physiological conditions like
pregnancy or growing age etc and degree of physical activity. Special care
has to be taken for growth and for weight control dietary regime. Accordingly,
required calorie should be distributed as CHO - 60 per cent, fat less than
20 per cent and protein can be 15 - 20 per cent of the total energy. Normally
10 per cent of energy comes from protein. Total fat intake is lowered to 20
per cent as diabetic patient have higher risk of atherosclerosis.
- If the diabetic person is overweight, shedding those
extra kilos by reducing calorie intake can help lower blood glucose levels.
- Due to lack of insulin, glucose can not enter the
cell and therefore, cells are starved of energy. It makes the person hungry,
weak and develop a craving for sugar. Small frequent meals, five- six times
will help them to manage their sugar level. High fiber diet will give satiety
as well as work as energy diluents. One can limit the number of calories per
day, without eliminating the favorite foods and therefore easy to continue
for long time.
- Often it is said that a diabetic person should not
have sweet fruits with free sugar in it. Fruits are rich in antioxidants which
have therapeutic value for diabetes and if we compare the CHO content of fruits
versus CHO content of bread, we will see that CHO content is much higher in
bread than in an equal quantity of any fruit that are restricted for diabetics.
Bread or any such starchy product may not be sweet but they are digested and
absorbed as sugar only. We must remember that diabetics may not have functional
insulin but they do not have any problem with their digestive system which
breaks starch to glucose only. Fruit should be given to diabetics but definitely
not in large quantities in one serving or along with other starchy products
so that the total glycemic load is controlled.
- It is often suggested that food with high glycemic
index should not be given to the diabetic patient. As mentioned before, glycemic
load is more important than Glycemic Index itself for this diabetic population.
Half a spoon of sugar in tea will increase postprandial sugar level to a much
lower level than a bowl of rice. But definitely if one takes rice instead
of equal calorific quantity of sugar, their stomach will be fuller.
- Amounts less than 100g of CHO is not advised as it
will lead to ketosis. Beside total amount of CHO, type of CHO and its distribution
between meals is extremely important.
- It is also very common that excessive control of
diet, higher dose of hypoglycemic medicine or insulin, excessive exercise
to facilitate blood sugar control, irregular insulin secretion or uncoordinated
drug and food intake may result in more dangerous effect of occasional hypoglycemia
(low blood sugar level) in hyperglycemic diabetic patients. In type I diabetes,
dose of insulin is the main reason for hypoglycemic reaction. When this hypoglycemic
effect is taking place at night (nocturnal hypoglycemia) it may get unnoticed
with severe consequences. The patient has to identify the signs and symptoms
of this hypoglycemic phase to be able to handle the blood sugar level. Bedtime
snacking is the suggested approach to prevent nocturnal hypoglycemia.
- Any time when there is a hypoglycemic attack one
must immediately give glucose/ sugar water as drink for faster absorption.
If the patient is unable to drink, then one can put sugar powder in the mouth
before one gets medical help. Here one point to remember is that symptoms
are similar for both acute hypo and hyperglycemic patient. If the patient
is hyperglycemic, little more sugar will not affect much and can be controlled
later by medicine. But if severely hypoglycemic, little sugar can save the
life. Therefore, one must treat with glucose water to a collapsing diabetic
person even though one has a doubt about the specific condition.
- The patient and the care giver should also be aware
of two of the most common types of hyperglycemic attack as Somoyogi Phenomenon
and Dawn Phenomenon.
- Somoyogi Phenomenon: Rebound hyperglycemia after
a period of hypoglycemia before meals or during the night is called Somoyogi
Phenomenon. Body adjusts hypoglycemia by releasing Epinephrine, Norepinephrine,
Cortisol, glucagons etc resulting in Hyperglycemia in the morning. One needs
to modify the insulin dose.
- Dawn Phenomenon: normal nocturnal glycemia, but
hyperglycemia is due to increased GH, in the morning. No modification of dose
of the insulin is needed. In such case, snacks may be taken little late to
cover the night period.
- Chromium and Zinc are the two most important elements
for the diabetic person. Sufficient Chromium is present in raw onion, broccoli,
tomato, and lettuce. Many foods contain some amounts of zinc and whole grains
are a better source of zinc than refined grains. On the other hand, the zinc
from meat is four times more bio-available than in grain foods.
It has been found that increasing intake of vitamins such as Vitamin C, E and
B6 and minerals such as magnesium can increase zinc absorption in the body.
E-mail: kasturisenray@netscape.net
Medical Advisor Manipal Cure and Care Private Limited
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