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August 2008  
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Home - Diabetes - Article

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.
Myths Regarding Diabetes
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.

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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