For youth with type 1 diabetes, to provide adequate energy to ensure normal growth and development, and to integrate insulin regimens into usual eating and physical activity habits. For youth with type 2 diabetes, to facilitate changes in eating and physical activity habits that reduce insulin resistance and improve metabolic status. For pregnant or lactating women, to provide adequate energy and nutrients needed for optimal outcomes.
For older adults, to provide the nutritional and psychosocial needs for the aging individual. For individuals being treated with insulin or insulin secretatogues, to provide self-management education for treatment (and prevention) of hypoglycemia, acute illnesses, and exercise-related blood glucose problems. For individuals at risk for diabetes and cardiovascular disease, or both, to decrease those risks by encouraging physical activity and promoting food choices that facilitate moderate weight loss or at least prevent weight gain. The basic principles are similar to those for the general population in that everyone needs daily macronutrients (a chemical required in large amounts) and micronutrients (a chemical required in small amounts) in appropriate proportions for optimal nutritional health and glucose control. The primary goal in the management of diabetes mellitus is to achieve as near normalregulation of blood glucose (postprandial and fasting) as possible.
Fiber is defined as the structural and storage polysaccharides and lignin in plants that are not digested in the stomach or absorbed in the small intestine, and intake should be encouraged. Over 20 studies have documented the safety and efficacy for decreasing LDL cholesterol concentrations by the use of phytostenols. Polyols are hydrogenated monosaccharides, and include such sugars as sorbitol, mannitol, and xylitol, as well as the hydrogenated disaccharides isomalt, maltitol, lactitol and tagatose.
The four non-nutritive, FDA-approved sweeteners have been found to be safe when consumed within FDA acceptable daily intake amounts. Sucralose (Splenda) is synthesized from regular sucrose such that the body does not recognize it, and is not absorbed. Stevia, derived from the plant stevia rebaudiana, is another non-caloric, natural sweetener. Resistant starches are defined as non-digestible oligosaccharides that are not digested and absorbed as glucose. The goal for dietary fat intake (amount and type) is similar for patients with heart disease but without diabetes and those with diabetes, due to the high risk of coronary vascular disease in patients with diabetes. Monounsaturated fats are typically found in vegetable oils such as olive oil, peanut oil and canola oil and remain liquid at extremely low temperatures. Polyunsaturated fats are usually liquid at room temperature, and are found in vegetable oils such as corn oil, safflower oil, soybean oil, and sunflower oil. In general, saturated fats are unhealthy because they increase LDL-cholesterol and total cholesterol concentrations. Trans fats are also called hydrogenated fats, which are fats created when oils are "partially hydrogenated". Relative insulin deficiency is associated with increased protein breakdown and gluconeogenesis, the process through which certain amino acids are converted into glucose. In patients with diabetes who have no underlying deficiencies, there is no clear evidence of benefit from vitamin or mineral supplements. Since diabetes is a state of increased oxidative stress, interest in recommending large doses of antioxidant vitamins has been high. In hypertensive, salt-sensitive individuals, reduced sodium intake can lower blood pressure. There is some evidence that dietary magnesium may help prevent type 2 diabetes, in both men and women.
Several recent studies have demonstrated a potential role for chromium supplementation in the management of insulin resistance, body weight, gestational diabetes and corticosteroid-induced diabetes. Both the amount and type of carbohydrate (CHO) in a food can influence blood glucose levels. The use of the GLYCEMIC INDEX (GI) (a scale that ranks carbohydrate rich foods by how much they raise blood glucose levels) has been studied and developed to identify and classify over 600 foods and their blood glucose raising potential.
The glycemic load (GL) combines the GI and the total CHO content of an average serving of a food. The initial diabetes meal plan should be based on the patient’s normal intake with respect to calories, food choices, and times meals eaten. Choose an insulin regimen that is compatible with the patient’s normal pattern of meals, sleep and physical activity.
Synchronize insulin with meal times based on the time action curve of the particular type of prandial insulin (rapid-acting analog insulin vs regular insulin).
Monitor blood glucose levels and adjust the dose of basal insulin and prandial insulin as needed for usual intake.
Monitor A1C, weight, lipids, blood pressure, and other parameters of interest, modifying the meal plan as necessary to meet goals.
With type 2 diabetes, the emphasis may need to be on making lifestyle changes to rectify metabolic abnormalities and meet weight loss goals. While medical nutrition therapy provided by registered dietitians resulted in better glycemic control in subjects with newly diagnosed type 1 diabetes, a recent survey of 45 pediatric clinics revealed that only 25 clinics had a pediatric dietitian available for children with diabetes . Emphasis on establishing supportive rapport with the family with simple instructions, more detailed guidelines later administered by the entire team, with focus on consistency in message. Nutrition guidelines should be based on dietary history of the family and child’s meal pattern and habits prior to the diagnosis of diabetes. Hypoglycemia usually occurs in patients taking insulin, but can occur in patients taking oral diabetes agents, especially a sulfonylurea.
Understand onset, peak, and duration of the insulin being used and the effect of increasing or decreasing the insulin dose. A list of sick foods, including sugar containing items, such as soft drinks and jello, should be provided. For patients using multiple daily injections (MDI), missed or delayed meals have greater consequence compared with patients on conventional insulin regimens. Blood glucose monitoring is necessary to adjust insulin dosing and carbohydrate intake, as well as to reduce hypoglycemic risk during exercise. The greatest risk for hypoglycemia results when the peak insulin action does not coincide with the peak postprandial glucose.
Alcohol intake greater than in moderation can lead to hypoglycemia through several mechanisms, including the inability of alcohol to be converted into glucose, the inhibitory effect of alcohol on new glucose production from the liver, and its interference in normal counterregulatory hormonal responses to impending hypoglycemia. After 15 minutes, blood glucose should be checked again to make sure that it is increasing.
Patients who take insulin or an oral hyperglycemic agent that can cause hypoglycemia, such as a sulfonylurea, should be advised to always carry one of the quick-fix foods with them. Driven by the explosive increase in the prevalence of obesity, the number of patients with known diagnosis of type 2 diabetes has reached massive proportions in the U.S. In a study by Van Dam, et al, the Western dietary pattern (high in processed meat, red meat, French fries, refined grains, high-fat dairy products, and sweets), was associated with a 59% greater risk of diabetes in adult men, while a prudent diet (high in fruits and vegetables, whole grains, fish, and poultry) was associated with a 16% lower risk of diabetes in adult men.
Two other widely publicized studies, the Finland Diabetes Prevention Study  and the initial results of the Diabetes Prevention Program , confirmed the importance of exercise and nutrition therapy as primary treatment after the initial diagnosis of type 2 diabetes is made.
While the general principles discussed in the first section apply to all patients with diabetes, those patients with type 2 diabetes and obesity (BMI 30.0 and greater) should have the major focus placed on weight loss and increased physical activity. The individualized approach to dieting shows powerful proof through the Weight Loss Registry, a roster of successful long-term dieters started 12 years ago.
Type 2 diabetes is becoming increasingly prevalent among young people who are driven, as is the case in adults, by lifestyle factors leading to increased body weight. Guideline approaches are less in-depth and complex, but they can offer the foundation for basic nutrition information. Diabetes Nutrition Guidelines illustrate the connection between diabetes and nutrition in a simplified format.
The First Step in Diabetes Meal Planning is a modified food pyramid that includes diabetic meal planning goals. The key take away message will be the following: there is no such thing as an 1800 calorie ADA diet!
However, appropriate nutritional treatment, implementation, and ultimate compliance with the plan remain some of the most vexing problems in diabetic management.
The major changes from previous recommendations include the following: 1) greater flexibility in the proportion of energy supplied by the macronutrients, particularly carbohydrates and monounsaturated fat, 2) liberalization of sucrose consumption, and 3) a focus on lifestyle changes, especially increased physical activity. The following guidelines will address the above goals and help put them to work for your patients. The amount and possibly the type of carbohydrate in a food greatly influence overall glucose control.
The range of carbohydrate intake should be 45-65% of total calories in agreement with the ADA and National Academy of Sciences-Food and Nutrition Board. A variety of high fiber foods such as legumes, whole grain breads and cereals, whole fruits and vegetables should be included as part of the daily carbohydrate intake. Plant sterols are naturally occurring cholesterol derivatives from vegetable oils, nuts, corn, woods and beans. Policosanol is an anitlipemic agent that includes mixtures of aliphatic alcohols extracted from sugarcane wax. Polyols are used as sweeteners and bulking agents, and designated GRAS (generally recognized as safe) by the FDA. Non-nutritive sweeteners elicit a sweet sensation to taste buds without increasing blood glucose or insulin concentrations. Aspartame is heat labile, breaking down into phenylalanine and aspartic acid, and thus can’t be used in cooking. The bitter aftertaste of acesulfame can be greatly decreased or eliminated by combining acesulfame with another sweetener.
Most recent guidelines from the NCEP recommend total fat intake of 25-35% of total calories (from mono or polyunsaturated sources) and saturated fat intake of <7%. Consuming monounsaturated fat has been observed to decrease total cholesterol, primarily by its lowering effect on LDL cholesterol, without an effect on HDL cholesterol. These fatty acids decrease the risk of artery blockage and heart attacks by their effect on decreasing platelet aggregation.
Polyunsaturated fats are also present in fish and fish oils, both of which help to decrease triglyceride levels. Diets high in saturated fats have been implicated in an increased risk of cardiovascular disease. The process of hydrogenation changes the chemical structure of unsaturated fats by adding hydrogen atoms, or “saturating” the fat. Exceptions include folate for prevention of birth defects (strong evidence) and calcium for prevention of osteoporosis (some evidence). The goal should be to reduce sodium intake to 2400 mg per day , which can be accomplished by not adding salt to foods and decreasing the use of pre-prepared and other salty foods. The FDA has recently issued a statement that there is not sufficient evidence at this time to support any of the proposed health claims for chromium supplementation.
Monitoring total grams of CHO by use of CHO counting or exchanges is a key strategy in achieving blood glucose control. It has been demonstrated that high fiber, low glycemic index foods can help delay the absorption of glucose into the bloodstream, consequently helping to control blood glucose levels. One need not count numbers or do any sort of mental arithmetic to make sure they are eating a healthy, low GI diet. It is defined as the weighted mean of the dietary GI multiplied by the percentage of total energy from CHO. Nutritional advice needs to be given to all caregivers; teachers, babysitters, extended family, etc.
Growth patterns and weight gain need to be assessed every 3-6 months and recommended dietary advice adjusted accordingly.
The general guidelines for macronutrients are similar to that of the adult diabetic population. Also, patients who work or participate in activities that make it difficult to plan or control meal times will have fewer issues if placed on a regimen that allows more flexibility in eating times. To reduce the risk of hypoglycemia, it is preferable to adjust the dose of insulin before the exercise begins. For example, the longer duration of action of regular insulin may lead to increased risk of late postprandial hypoglycemia, compared with rapid-acting insulin analogs.
However, one drink for women and 2 drinks for men per day can usually be incorporated into the diet for patients with type 1 diabetes with no untoward effects on blood glucose.
Wearing a medical ID bracelet or necklace is also a good idea, as well as having a glucagon emergency kit handy. For men who ate a Western diet, the risk for diabetes was even greater if they were also obese or had a low level of physical activity. The diabetogenic process may begin as early as fetal life, with low birth weight and poor nutrition combining with sedentary lifestyle and dietary factors to produce an insulin-resistant phenotype that may accelerate the development of renal pathology and cardiovascular disease.
In some cases, guidelines alone may be enough to change eating behaviors in some patients with diabetes. An explanation and picture of the guide is listed earlier in this chapter under section E, Children and Adolescents. Healthy Food Choices is a pamphlet primarily used for the initial stage of diabetes meal planning. It can be used as a “stand alone” guideline for a patient unable or unwilling to see a dietitian, or for a patient who has an unusual delay before individualized meal planning education can begin. They are designed to be interactive, with the emphasis on problem solving and setting goals. The modern diet for the diabetes patient is based on concepts from clinical research, portion control, and lifestyle changes.
This issue emanates from two sources: First, there are different diets to consider, depending on the type of diabetes.
Resnick, et al, recently reported that achievement of ADA clinical practice recommendations is far from adequate in U.S. The Diabetes Control and Complications Trial (DCCT) and other studies demonstrated the value individualized consultation with a registered dietitian familiar with diabetes treatments, along with regular follow-up, has on long-term outcomes . The total amount of CHO (carbohydrate) consumed is the strongest influence on glycemic response.
A fiber rich meal is processed more slowly, which promotes early satiety, may be less caloric, lower in fat and added sugars, which can combat obesity and also may prevent risk of heart disease and colon cancer . It is used in 25 other countries, mainly South America and the Caribbean, to lower LDL cholesterol.
Available evidence from clinical studies shows dietary sucrose has no more effect on diabetes control than does equivalent caloric amounts of starch. Polyols are only partially absorbed from the small intestine, allowing for the claim of reduced energy per gram.
Cyclamate (Sugar Twin) remains available in Canada, although it was banned in the U.S in 1970.
It should be kept in mind that too much of any type of fat will, as a general rule, increase overall caloric intake, with resultant increase in body weight and total cholesterol. Fish with high amounts of omega-3 include salmon, albacore, tuna, mackerel, sardines, herring and rainbow trout.
While polyunsaturated fats decrease LDL cholesterol and total cholesterol, they unfortunately also decrease serum HDL cholesterol. Indeed, the cholesterol content of the food may be less important than the amount of saturated fat contained in that food. There is no risk of developing protein malnutrition when consuming a usual diet of approximately 20% protein. Although deficiencies are difficult to determine, once identified, supplementation can be beneficial.
There is also interest in a role for niacin in preserving beta cell mass in newly diagnosed type 1 patients.
The DASH (Dietary Approaches to Stop Hypertension) diet, which is high in fruit and vegetables, low-fat dairy products, and low in saturated and total fat; has been shown in large, randomized, controlled trials to significantly reduce blood pressure.
As a general rule, refined grain products and potatoes have a higher GI, legumes and whole grains have a moderate GI, and non-starchy fruits and vegetables have a low GI.
All patients whose treatment regimen includes a sulfonylurea or insulin should be educated regarding management of meal time with their respective pharmacological approach. On the other hand, if the exercise is unplanned, a carbohydrate supplement should be taken before the exercise begins. In addition, when the premeal insulin dose is too large for a particular meal relative to its CHO content, hypoglycemia can result.
While these results do not prove that eating a Western diet causes type 2 diabetes, they certainly add to existing evidence that eating these types of food increases the risk for developing type 2 diabetes, and that being overweight and lack of exercise increases the risk even further.
Most patients are looking for the quickest and easiest way to lose weight, and most have unrealistic expectations. At 4,800 members, the Registry is now the largest collection to date of long-term weight-loss data. Guideline approaches focus on making healthy food choices without weighing or measuring foods, using exchanges, or counting calories, fat or carbohydrate. It includes an overview of diabetes nutritional management within the framework of basic eating guidelines. Created by a working group of the American Diabetes Association Nutrition Education Resources Steering Committee, this tool is written at a 5th to 7th grade reading level. Examples of topics include “Older persons with diabetes”, “Supermarket smarts” and “What about sugars?” A professional guide is included with the resources. Second, a plethora of dietary information is available from many sources: some are right, some are wrong, some are contradictory, and most are confusing. Sucrose has an affect on glycemia similar to other forms of CHO and can be substituted for other CHO sources within the context of a healthy diet. Recent studies consistently, but not unanimously, support a 20-30% reduction in the risk of development of type 2 diabetes with increased cereal and whole grain fiber intake.
Two margarines containing phytosterols are approved by the Food and Drug Administration (FDA) to lower cholesterol.
Several studies in patients with diabetes have demonstrated a reduction in post-prandial glycemia when fructose was used in place of starch or sucrose as the CHO source.
The controversy centered around the role cyclamate might play in the development of bladder cancer in rats.
Saturated fats raise cholesterol levels and LDL-cholesterol levels more than dietary cholesterol itself.
Due to an increase in albumin excretion rate, intake of protein above this range may be a risk factor in developing diabetic nephropathy. To minimize this risk, consumption of protein should be kept at RDA level, providing approximately 10% of total daily caloric intake. Specific populations, such as the elderly, pregnant or lactating women, strict vegetarians or vegans, and patients on calorie-restricted diets may benefit from a multivitamin mineral supplement.
Many factors can influence the GI of a food, such as methods of cooking, physical state of a food, and how much fat and protein are consumed with that food.
The GL corresponds rather closely to the grams of carbohydrate in a serving, not the actual GI of the food. Carrying a source of carbohydrate at all times is mandatory, and use of food to prevent hypoglycemia when a meal is missed or delayed should be taught. All patients who use insulin should have a glucagon emergency kit on hand to be used in case of severe hypoglycemia. Depending on the blood glucose level at the start of exercise, as well as length and intensity of the activity, a snack should be consumed before, during and after the exercise. Such a mismatch may occur due to errors in estimating CHO or food intake in patients on multiple daily injections (MDI) or on insulin pumps. Lack of exercise and an overabundance of readily available foods (usually containing too much fat) lead to obesity and in many cases the metabolic, or insulin-resistance syndrome. Obesity does not occur overnight, and its treatment requires lifetime adjustments to food (energy) intake and energy expenditure (increased activity). Regardless of whether they are used alone, or in combination with a specific meal plan, guidelines are a good choice for beginning education about nutrition.
Other resources may be added to this tool, as appropriate, to move the patient toward more in-depth management. Different types of diabetes require some specialized nutritional intervention; however, many of the basic dietary principles are similar for all patients with diabetes. Monitoring total grams of carbohydrate, whether by use of food exchanges or carbohydrate counting, can be a useful tool in achieving good glycemic control, especially for patients with type 1 diabetes. Insulin resistance may be reduced with high intakes of whole grain fiber, but additional studies are needed to determine optimal amounts. This may be difficult for some people with diabetes, as large amounts of fiber can cause negative GI effects, such as bloating and gas.
However, the observation that consuming large amounts (15-20% of total daily energy) of fructose increases fasting total and LDL cholesterol may decrease the benefit of fructose. Studies of subjects with and without diabetes have shown that sugar alcohols cause less of a postprandial glucose response than sucrose or glucose.
In human studies over a period of 30 yeas, no association has been observed between the use of cyclamate and bladder tumors. A recent analysis of the glycemic index from randomized controlled trials indicates that using the glycemic index may provide an additional benefit over total carbohydrate intake alone.
There is not enough evidence currently to use either the GI or GL as a method of meal planning alone for people with diabetes, but a recent randomized controlled study demonstrated that diets high in carbohydrates (high GL) with low glycemic index (GI) are best for cardiovascular risk reduction.
Insulin calculations can be based on food exchanges, carbohydrate counting, or predefined, set menus. Consuming alcohol in a fasting state may contribute to hypoglycemia in patients with type 1 diabetes. The glycemic index (the scale that ranks carbohydrate rich foods by how quickly they raise blood glucose levels) has also been shown to have a small, but clinically significant effect on improved blood glucose control. If the patient is not accustomed to larger amounts of fiber in their diet, it should be added slowly.
Policosanol is not FDA approved for reduction of LDL levels in the United States, but many consumers purchase policosanol as a nutritional supplement over the counter or through various Internet sources. Resistant starches may produce smaller increases in postprandial glucose than digestible starch, but studies to date have been inconclusive on this subject.
Carbohydrate counting is routinely taught to patients with diabetes, so that they can more easily estimate the amount (grams) of CHO in a particular food. Intense or prolonged exercise may call for an additional snack after the exercise or before bedtime.
The cause of the obesity epidemic is that most people consume more energy than they burn, and the excess energy is stored as fat. Some manufacturers have started adding them to foods for their cholesterol lowering effects. Furthermore, setting CHO counting goals for each meal allows the patient to more easily match their CHO intake to the appropriate mealtime insulin dose. For example, a patient could compare a low GI food, such as oatmeal (GI = 50) with cornflakes (GI = 84) to determine the relative effect of each on blood glucose. Lastly, reduction of insulin dose after longer, more intense periods of exercise may be necessary to prevent hypoglycemia. However, any changes in insulin or food intake requires further adjustment of one or the other, or both. The old adage remains true: “to lose weight ‘calories in’ must be less than ‘calories out’”. You can now get phytostenols in margarine spreads, orange juice, cereals, and even granola bars.
Although a diet high in polyols could reduce overall energy intake or provide long-term improvement in glucose control in diabetes, such studies have yet to be done. Advantages of CHO counting include improved glucose control, flexibility in food choices, and simplification of meal planning. Disadvantages include potential weight gain, unhealthy eating, hypoglycemia and high lipid levels. Patients taking rapid-acting insulin may choose to give their insulin dose after the meal, if unsure of amount of food to be consumed. There are no evidence-based studies showing superiority over other dietary management methods, and CHO counting requires motivation on the patient’s part. This approach can be especially helpful in children, nausea related to pregnancy, or other illness. If a smaller than normal meal is eaten, guidelines are available for reducing the insulin dose, or carbohydrate replacement in the form of fruit or fruit juice can be given, depending on the patient’s particular insulin regimen. Weight loss is a major challenge for most patients who, in our fast-paced environment, don’t eat properly and fail to establish patterns of regular physical activity. The key to success is having a patient with diabetes commit to establishing a healthy lifestyle that emphasizes and incorporates more healthy food choices and a daily exercise routine, taking into account the presence of possible complications.
Developing an individualized weight loss program preferably with a registered dietitian familiar with diabetes management, along with regular follow-ups, will help promote success. It is always important that a patient check with their physician before starting an exercise program.
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