Nutrition Therapy in Diabetes Mellitus type 2

Nutrition Therapy in Diabetes Mellitus type 2

Introduction

Diabetes is a chronic disease that requires changes that last a lifetime. The management of diabetes includes medical nutrition therapy (MNT), medications, exercise, blood glucose monitoring, and self-management education/behavior modification.

 Type 2 diabetes should not be viewed as a less severe version of type 1 as it is a highly malignant condition with 50% of affected individuals dying within 10 years of the diagnosis.

A major contributing factor to the development of Type 2 diabetes is body weight and the incidence of type 2 diabetes begins to rise at a BMI of 23 kg/m2.

The overall goal of diabetes management is to help individuals with diabetes and their families gain the necessary knowledge, life skills, resources and support needed to achieve optimal health. This requires a team effort that includes diabetes health care professionals and the individuals who must deal with this chronic condition on a daily basis. The dietitian is a key member of the health care team, who plays an integral role in the individualization of management strategies for people with diabetes and those at risk for developing it.

General Principles

 In general, nutrition advice for people with diabetes is the same as that for all people, and follows the principles for healthy eating:

The optimum healthy choice of food for people with diabetes is the same for the general population

Enjoy a variety of foods. .

A regular meal pattern based on starchy carbohydrate foods such as bread, potatoes, rice, and pasta .Choose wholegrain foods where possible. Replace fried food with grilled or steamed

Emphasize cereals, breads and other whole grain products, vegetables and fruits.

Choose lower-fat dairy products, leaner meats and foods prepared with little or no fat. replacing saturated fat with monounsaturated rich fats and oils

Achieve and maintain a healthy body weight by enjoying regular physical activity and healthy eating.

General Principles

The goals of medical nutrition therapy

Achieve and maintain optimal blood glucose and lipid levels through appropriate food choices.

Improve quality of life and overall health.

Empower persons to self-manage their diabetes by providing information to increase their knowledge and skills.

Teach prevention and treatment of the acute complications of hypoglycemia, hyperglycemia

The goals of medical nutrition therapy

Provide adequate energy and nutrients for attaining and or maintaining a reasonable weight for adults and normal growth and development rates for children and adolescents, and meeting increased needs during pregnancy, lactation, or recovery from illness (reasonable weight is considered the weight an individual and health care professional agree upon to be achievable and maintainable; both short term and long term this weight may be different than desirable body weight).

Reduction of weight in obese patient to reduce insulin resistance.

Prevent or delay the long-term complications of diabetes such as retinopathy, nephropathy, and cardiovascular disease (secondary prevention).

     Weight management and monitoring glycaemic conttrol

More than 80% of people diagnosed with type 2 diabetes are overweight.  Weight management in type2 diabetes is important to help to reduce insulin resistance, control blood glucose levels, and lower the risk of long-term complications. Although preventing weight gain and/or reducing excess body weight can be very challenging, it is central to optimizing diabetes care and is a cornerstone in the dietary management of diabetes.

Monitoring of glycaemic control

Glycosylated hemoglobin (HbA1) should be measured at least annually. values ≤7% are considered a desirable target for most patients with type 1 and type2 diabetes, and are associated with a reduced risk of complications.

 3. Diet therapy

Energy Intake

 - Daily requirements to non-obese diabetic patient are the same needs of healthy person at the same age, sex, height and type of effort. Obese Diabetic (type II) must follow a reduced total Kcal by 500 kcal per day.

-               Resting Energy Expenditure (REE) method:

(Men) = 66.5 + [(wt x 13.75) + (ht x 5.0) – (age x 6.78)]

(Women) =655.1 + [(wt x 9.56) + (ht x 1.85) – (age x 4.68)]

Protein

 Typically, protein accounts for approximately 12 to 20% or more of total calories consumed. At present, scientific evidence does not support either a higher or lower protein intake for the person with diabetes, and protein intakes in the range of 10 to 20% of daily calories are recommended (RDA). In the presence of diabetic nephropathy, protein should not exceed 0.8 g/kg or 10% of total calories.

Protein intake should not go below 0.6 g/kg/day

Fat

 Fat intake generally should not exceed 30% of energy. Most importantly, saturated fats, because of their atherogenic potential, should be held at a maximum of 10% of energy needs.

      Polyunsaturates, with their tendency to lower HDL-cholesterol values and their susceptibility to oxidation, should also be held under 10%.

      monounsaturated, should be at or  more 10% ; sources such as: canola or olive oils.

 Cholesterol intake, though less influential than saturated fats on serum lipid values, should be held under 300 mg/day. These are consistent with those of the American Heart Association and other groups.

Fat

If LDL cholesterol level elevated

-Saturated fat 7% of kcal

-Cholesterol < 200 mg daily

FISH OILS (n-3)

evidence showing that fish oils can reduce plasma triglycerides and VLDL concentrations in the diabetic population, as well as reducing blood pressure.

there are also potential effect of fish oils on LDL cholesterol and glycaemic control in people with diabetes.

Types of fat

CHO

Carbohydrate depends on the state of the patient's case, food habits and nutritional goals. CHO should provide 50 to 60% of energy intake. Simple CHO (not as severely restricted in the past) should make  less than 1/3 of total CHO intake. Addressing a sufficient quantity of carbohydrates is important for all individuals, as well as for diabetics.

Total carbohydrate – more important than the type of carbohydrate consumed

Choose foods and beverages with little added sugar or kcaloric sweeteners

Artificial sweeteners (aspartame, saccharin) used in  place of sugar.

Food Sources

Grains, vegetables and fruits are a good source of Carbohydrates, it also provides us with vitamins, minerals and fiber. And  diabetic’s attention for Carbohydrates must be on total quantity rather than rely on food sources.

             Vitamins and Minerals:

There is a need for more conclusive evidence on the benefits of vitamins and antioxidant nutrients in terms of protection from cardiovascular disease and general health benefits for the diabetic and non-diabetic population.

Pharmacological doses of supplements are therefore not advised. However, it is recommended that a diet rich in foods which naturally contain significant quantities of antioxidants, especially fruit and vegetables, is followed.

 When food is balanced for diabetics there is no need for the

use of vitamins and minerals supplements. 

Alcohol use in DM

May use in moderation

Women – 1 drink/day   

Men – 2 drinks/day

 

Should consume food with alcoholic beverages – to avoid hypoglycemia

Interfering with gluconeogenesis in the liver

 

Excessive alcohol intakes can worsen hyperglycemia – raise triglyceride levels in some individuals

Abstention recommended with:

Pregnancy

Pancreatitis

Advanced neuropathy

Abnormally high triglyceride levels

          Table Salt :

             Often  diabetic Patients suffer from hypertension, where the salt plays role in that. Therefore, diabetic patients are advised not to eat more than 3000 mg of sodium daily. And in the event of a  high blood pressure for patients with diabetes ,patient must  reduce the proportion of sodium to 2400 mg or less daily. And for patients who suffer from high blood pressure in addition to the renal failure,  reducing the deal to 2000 mg sodium or less per day.

Fiber: 

The intake of an adequate amount of dietary fiber is considered very important.

the daily fiber requirements  for diabetic patients   is similar to the requirements of healthy people,  20- 30 g of fiber daily to  prevent constipation and reduce cholesterol and glucose levels.

Insoluble fiber:  (cellulose, hemicelluloses)

Soluble fiber: (gums and pectin)

      found in fruits and vegetables is more beneficial than insoluble fiber in DM, because it decreases the post-prandial glycaemia and acts favorably on blood lipids. 

Micronutrient intakes

Folate supplements during pregnancy – prevent neural tube defects

 

Calcium supplements to reduce osteoporosis risk in older adults

 

Chromium supplementation not recommended for persons with DM2

 

Physical Activity

There is now unequivocal evidence that physically fit people are less likely to develop Type 2 diabetes and some intervention trials have shown that encouraging people with impaired glucose tolerance (IGT) to increase their physical activity significantly reduces their risk of developing diabetes .

This benefit is independent of body mass index (BMI) and there is some evidence that physical activity has a greater protective effect as BMI increases . It may be of more importance for people at risk of Type 2 diabetes to increase their physical fitness rather than concentrate on weight reduction.

Physical Activity

The practice of sport is very important for diabetics. Programme activities include exercise average of 20-30 minutes of air activities such as walking and scrambling at least three times a week:

 

        Improves the ability of the body to make use of glucose and increase insulin sensitivity.

          Adjusts the level of lipids in the blood and helps to increase weight loss.

           Reduces the requirements for insulin up of 10 - 20%.

           They also improve blood circulation and

           stimulate the muscles and give a sense

           of vitality and pay the morale of the patient.

Physical Activity

§   Blood glucose levels drop during activity.

§   Don’t inject insulin prior to exercise.

§   If blood glucose below 100 mg consume carbohydrate prior to exercising

§   During exercise:

.20–30 min of light/moderate activity should not require extra CHO

.30–60 min of moderate activity may require an extra 10–20g CHO

.30–60 min of strenuous activity may require an extra 30–50g CHO

§    Remember to consume adequate fluid to prevent dehydration And Proper footwear.

Nutritional Status Assessment in Diabetic Patients 

q Anthropometric measurements recorded:

. Height (m)                              . Weight (kg)

. BMI (kg/m2)                            .  Waist circumference (cm)

Clinical finding

Laboratory which might include:

. Blood pressure

. Fasting/random blood glucose (mmol/l)

. HbA1c (%)

. Total, HDL and LDL cholesterol levels (mmol/l)

. Triglycerides (mmol/l)

and where appropriate indicators of renal function (and liver function).

Meal Planning

To help the patient meals plan better, options include:

exchange lists

carbohydrate counting

Menu approach. (See Sample menu

   for a diabetic patient)

Exchange lists

Exchange lists serve as the basis for a meal-planning system recommended by the ADA. The lists simplify meal planning, help the need for daily calculations, and ensure a consistent intake.

 Sorts foods according to their proportions of carbohydrate, fat, and protein – each item in the group is similar in macronutrient and energy content

Exchange lists Table

Carbohydrate counting

Carbohydrate information on food labels has simplified carbohydrate counting. The system is easier to learn than the exchange lists system, gives the patient more flexible food choices, and provides a better estimate of how much the blood glucose level will rise after a meal or snack. Also, if the patient takes insulin, carbohydrate counting can be helpful in determining insulin dosages.

Menu approach

In the menu approach, the patient and dietitian collaborate to develop menus tailored to the patient’s needs and preferences. As the patient desires, menus may be relatively flexible, dictating specific foods and the amounts that the patient must eat at specific times.

The menu approach is best for patients who have fairly regimented eating habits or who want to be told exactly what and how much to eat.

Example

  - Gender: female – (non pregnant)     

       - Age: 45 years

       - Height: 170 cm

       - Weight: 95 kg

       - Diagnosis: DM (type 2)

       - Activity level: sedentary

Method 1:

         655.1 + [(wt * 9.56) + (ht * 1.85) – (age * 4.68)] * AF

         655.1 + [(65 * 9.56) + (170 * 1.85) – (45 * 4.68)] * AF

         655.1 + [(621.4) + (314.5) – (210.6)] * AF 

        (655.1 + 725.3) = 1380.4 kcal per day

Method 2:     Add activity factor

      1380.4* 1.2 = 1656.48 = 1650   Kcal per day

 

CHO = 60 %         -   1650  * 0.60 =  990 kcal  / 4 gm=  247.5 gm                                      

Protein = 20 %      -  1650 * 0.20 =  330 kcal  / 4 gm =  82.5gm                                       

Fat = 20%             -  1650* 0.60 =  330kcal  / 9 gm =  82.5gm                         

 Diabetes in special groups

Nutrition therapy for pregnant women with diabetes and GDM:

      is individualized on the basis of the nutrition history, pre-pregnancy weight, and physical activity levels. Generally, an additional 100 to 300 cal/day is added to the meal plan at the beginning of the second trimester. Three main meals and 3 snacks are recommended.

Adequate nutrition for mother and fetus, this should meet all the nutrient requirements of pregnancy through the provision of regular meals that include a large component of slowly absorbed carbohydrate.

Energy intake that limits unnecessary maternal weight gain

Nutrition therapy for pregnant women with diabetes and GDM

Recommended pregnancy weight gain in women with gestational diabetes :

             BMI             Weight gain(kg)

                 <25                   10-12.5

                 25-30                  7-11.5

                 30-34                  7

                 >34                    0    

Limiting weight gain in pregnancy is controversial but in obese women with GDM is associated with decrease risk of hypertension, CS, large for gestational age babies but no increase in risk of preterm delivery or small for gestational age babies , and Blood sugar level should be monitored regularly and insulin dose and frequency adjusted to maintain capillary between 4.4-6.1 mmol/l before meals and<8.6mmol/l after meals.

  Diabetes in children and adolescents

The nutrition prescription is based on the nutrition assessment. Newly diagnosed children often present with weight loss and hunger, and as a result the initial meal plan must be based on adequate calories to restore and maintain appropriate body weight. Several formulas can be used to confirm that a child or adolescent is receiving the minimum number of             calories necessary for growth and development.

Diabetes in children and adolescents

Height and weight should be recorded on growth charts every 3 to 6 months to make sure children are growing normally. If not, the overall diabetes management needs to be assessed. Caloric needs in children change continuously, and, therefore, food intake should be evaluated every 3 to 6 months.

Daily eating patterns in children generally require three meals and three snacks, depending on the length of time between meals and physical activity level. The purpose of the snacks is to prevent hypoglycemia between meals.

Estimating Caloric Requirements for Youth

- Base calories on nutrition assessment

- Validate caloric needs

   Method 1: NAS/RDA Guidelines

   Method 2: 1000 kcal for 1 st year

                     Add 100 kcal/yr up to age 11

                    Girls 11-15 yr,add 100 kcal or less/yr

                    Girls > 15 yr, calculate as an adult

                    Boys 11-15 yr, add 200 kcal/yr

                    Boys > 11-15 yr, 50 kcal/kg very active

                                               40 kcal/kg usual

                                               30-35 kcal/kg sedentary

   Method 3: 1000 kcal for 1 st year

                    Add: 125 kcal x age for boys

                             100 kcal x age for girls

                             up to 20% more kcal for activity