Dietary management in Diabetes Mellitus- Medical nutrition therapy

Dr . Abhijeet Deshmukh

Goals

• Provision of adequate nutrition & balanced calories for– Normal growth & development.– Prevention of Hypo/ Hyperglycemia.

• Change in eating behaviors & promote physical activity to – Reduce insulin resistance & improve metabolic

control.

• Biochemical goals– FBS< 115 mg/dl, – PPBS < 126mg/dl ,– Sr Cholesterol < 200 – LDL < 130– HDL > 50 TGs < 160– Glycated Hb -6-8 gm%

Meal Plan

• High fibers , low fat diet with adequate calories & proteins.

• Carbohydrates- 50-60%, Fat- 20-30%, Proteins 10-15%• According to familiy’s religious beliefs & eating

habits.• Insulin therapy & Self blood glucose monitoring

(SBGM) integrated.• Avoid fasting & feasting.

• Individualised flexible nutrition plan to facilitate compliance.

• Regular meal timing, consistent quantity, relatively fixed composition,

• Thorough review of dietary intake annually or earlier if– Unexplained growth failure,– Unexplained Hyper/ Hypoglycemia,– Excessive wt gain/ loss,– HTN, Hyperlipidemia, Nephropathy, Elevated Hb A1 C

Nutritional Intervention

• Offering structure for meal planning-1. Menu based2. Exchange list based3.Carbohydrate counting (Preferred)• It includes 4 steps-1. Assessment2. Goal setting 3. Intervention 4. Evaluation

1. Assessment– 24 Hr recall food history– Carbohydrate intake per meals & snacks– Other factors : Timing of meals, Timing & Amount

of exercise, Frequency & Rx of hypoglycemia.– Assess readiness of patient for change in diet.

2. Goal setting– Diet & lifestyle changes– Metabolic outcomes

3.Intervention Level 1– Practice identifying carbohydrate foods– Recognize 10-15 gm carbohydrate portion of

foods.– Plan sample meal

• Level 2– Blood glucose reading– Maintain physical activity log

• Level 3– Calculate carbohydrate: Insulin ratioi.e. Total gm of carbo. Per meal: Units of rapid acting

insulin analogue taken before meal.

4. Evaluation– Access effect of intervention

Calories distributed with NPH (Lente) regimen

• Breakfast 20%• Lunch 20%• Dinner 30%• Snacks– Midmorning : 10%– Mid afternoon : 10%– Evening : 10%

• Carbohydrates– 55 % of total calorie intake– Avoid rapidly absorbed mono/

disaccharides(Simple) & refined sugars like glucose, sugar, honey etc (30%)

– Encourage complex carbohydrates like starch -70%

– Wheat is preferred over rice(Acarbose : slow absorption)

– Tubers restricted– Minimum daily carbohydrate intake > 130 gm

above 1 yr of age

• Exchange system : to ensure fixed energy intake and avoid monotony

• 1 exchange system: 10 gm of carbohydrate– ½ slice bread, ½ banana– 1 glass of milk, 1 glass of curd– 1 cup thin soup, 1 cup porridge– 1 tomato/ apple/ orange

• Glycemic index:– Increase in RBS following ingestion of single food

as % of increase following standard food– Glucose 100%, potato 90%, rice 72%, wheat 65%,

ice cream 43%, apple 40%, soyabean & peanut 20%

– Food items with low glycaemic index are encouraged

– Not much of significance, affected by multiple factors

Exercise

• ↓ insulin requirement and LDL, ↑ HDL• Provide extra calories for exercise– No exercise until RBS < 300 mg%– No extra calories if RBS 180- 300– Extra calories if RBS < 180

Type of exercise Carbohydrtes to be given gm/hr of exercise

Food item

Mild (< 30 min) 10-15 before 1 fruit

Moderate (1 hr) 25 Before

10-15 after

½ sandwich+ 1 glass milk

1 fruitSevere ( 1-2 hr) 50 Before

10-15 after

1 sandwich+ 1 glass milk

1 fruit

• Fruits: when blood sugar is well controlled ½ to 1 fruit at the expense of snacks or after exercise

• Carbohydrate content:– < 5%: cabbage, spinach, brinjal, cucumber,

drumsticks, tomato, watermelon– 5-20%: cauliflower, beat root, peas, ladies finger,

papaya, apple, orange, strawberry, grapes, lime, mosambi

– > 20%: potato, banana, jack fruit

• Fibers:– 25-35 gm/day– Unabsorbed plant polysaccharides– Delays carbohydrate absorption, decreases

hyperglycemia, increases insulin receptors, decreases insulin requirement

– Pectin, gums- bind to bile salts, increase their excretion, hence decreases cholesterol

– Ragi, pulses, ground nut, guava- 3-5% of fibers

FATS

• 30% of calories• Saturated fat < 10% calories,

with elevated LDL< 7 %• PUFA up to 10% of calories• PUFA/ saturated fat 1.2:1• Infants and children < 2 yrs , no restriction of

dietary fat• Avoid animal fat and hydrogenated oil• Fish and chicken preferred to beef and egg

• Turmeric , Bengal gram, onion, garlic- decreases cholesterol

• If cholesterol is increased rule out autoimmune hypothyroidism

• Low fat– Increases insulin binding– Decreases LDL, VLDL

• PROTEIN:15 % of total calorie intakeif nephropathy 8-10%microalbuminuria 0.8 gm/kg/d

Sweeteners

• Non nutritive:– Improves palatability without increasing energy intake– Saccharin, aspartame, accusulfame, neotame, sucralose– Saccharin may cause hepatic and bladder malignancy

• Nutritive:• sucrose:

– No adverse effect in usual amounts– Should not be restricted– Counted in tally of carbohydrtes

• Fructose:– May be chanelled into glucose pathway, so avoid

• Na - < 3 gm/day < 2.4 gm/day if HTN• Vitamins and minerals: as per regular

requirement

Hypoglycemia

• Decreased food intake, increased activity• Goal: rapid normalization of blood sugar

without use of excess food thus avoiding resultant hyperglycmia

• Management: 1. Simple sugar( juice, glucose tablets) rapidly absorbed, raise blood sugar within 10-15

mins 15 gms = 30 mg/dl2. Repeat RBS after 15 mins, if < 80 give one exchange( 15 gm)3. Repeat after 10 mins, if > 80 give 15 gm carbohydrate with protein snack or

planned meal/ snacks within 30-60 mins

Thank You