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Nutritional And Exercise Advice For Diabetic Patients

V.G.Kuchake

V.G.Kuchake

A major goal for diabetes care is to improve glycaemic control by balancing food intake with endogenous and/or exogenous insulin levels. For people with Type-1 diabetes, insulin doses need to be adjusted to balance with nutritionally adequate food intake and physical activity.

For individuals with Type-2 diabetes, impaired glucose tolerance or impaired fasting glucose, attention to food type and weight management combined with physical activity may help improve glycaemic control. Nutrition and all forms of diabetes management should be individualized. The management of diabetes can be undertaken by consumption of sucrose, more active promotion with a low glycaemic index, and greater emphasis on the provisions of nutritional advice in the context of wide lifestyle changes; particularly physical activity. The role of exercise in preventing the progression from insulin resistance to impaired glucose tolerance and overt hyperglycaemia has also been recognized. The main purpose of this article is to provide information about nutritional advice and exercise for diabetic patients. Diabetes is a group of syndrome characterized by hyperglycemia; an altered metabolism of lipids, carbohydrates and proteins and an increased risk of complication from vascular disease1.It is divided symptomatically as having either insulin dependent diabetes mellitus (IDDM or Type–1 diabetes) or non insulin dependent diabetes mellitus (NIDDM or Type –2 diabetes). According to the types of diabetes, Type –2 takes place because of the failure of β-cells in the presence of persistent insulin resistance while Type-1 diabetes always needs insulin therapy for their very survival2.

Diabetes is a global epidemic that affects more than 150 million people worldwide3. In the United States, an estimated 16 million people have diabetes; more than 800,000 cases are diagnosed annually. Diabetes has become the sixth leading cause of death in America and the major cause of disability from disease in the United States4.

The goal of diabetes management is the prevention of acute and chronic complication of the diabetes mellitus. Traditional chronic complications of diabetes mellitus are viewed as the microvascular complications including retinopathy, nephropathy and neuropathy. Nevertheless, macrovascular complications of diabetes are more prevalent and are the major cause of disability and death in patients with diabetes mellitus.

Prevention and management strategies are different for type -1 and Type –2 diabetes. Consumptions of suitable diet5,6 is given in Table- No.- 1, for example, sucrose for patients who are not overweight can be increased up to 10 % of daily energy derived from carbohydrates. The increasing evidence in the importance of good metabolic control and the growing requirement for the measures to prevent type-2 diabetes in an increasing obese population will require major expansion of diabetic services. 

Table No.1- Composition Of Diet

Components

Comment

Protein

Not >1 g/kg body weight

Total fat

<35% of energy intake

Saturated + Transunsaturated fat

<10% of energy intake

n-6polyunsaturated fat

<10% of energy intake

n-3 polyunsaturated fat

Eat fish once or twice weekly, Fish oil  supplements not recommended

Cis-mono unsaturated fat

10-20%

Total carbohydrate

45-60%

Sucrose

Up to 10% of daily energy

Fibre

No quantitative recommendation

Vitamins and antioxidants

<6g sodium chloride/day

Nutritional Advice To Diabetic Patients

Aims and Objectives of nutritional advice

Nutritional advice and information is essential for the prevention of diabetes in those at risk of Type-2 diabetes and for effective management of the condition in those with Type-1 and Type-2 diabetes. The aim is to provide those who need advice with the information required to make appropriate choices on the type and quantity of the food, which they eat. It must be adapted to the specific need of an individual, which may change with time and circumstances, e.g. age, pregnancy, nephropathy, undercurrent illness and other illness5,6.

The objectives of dietary advice are as follows
  • To maintain or improve health through appropriate and healthy food choices7,8 is given in Table No. - 2.
  • To maintain and achieve optimal metabolic and physiological outcomes; including reduction of risk for macrovascular disease, by achieving near normal glycaemia without undue risk of glycaemia, including management of body weight, dyslipidemia and hypertension.
  • To optimize outcomes in diabetic nephropathy and in any concomitant disorder such as coeliac disease of cystic fibrosis.

Table No.2- Food Choices

Choices

Comments

Nutritive sweeteners

No proven advantage over sucrose

Fructose

No reason to avoid naturally occurring fructose in fruits.

Sugar alcohols

Lower calorigenic effect but no other advantage over sucrose may cause diarrhoea.

Non – nutritive sweeteners

Useful in beverages, potentially useful in overweight.

Diabetic foods

Unnecessary expensive may cause diarrhoea.

Not recommended.

Plant stanols and sterols, Fat replacers and subtituents

Approx.2g/day can reduce LDL cholesterol by 10-15%.

May facilitate weight loss.

Herbal preparation

Long term studies needed.

No convincing evidence of benefit.

LDL-Low Density Lipoproteins

Nutritional advice for the diabetic patient for control of diabetes mainly by record of body weight and shape, energy expenditure composition of food, body weight management, and carbohydrate management are as follows:

Body weight and shape

Most people with Type-2 and may of those with Type-1 are overweight. WHO has defined obesity as, “A disease state in which excess fat has accumulated to an extend that health may be adversely affected,” and has categorized normal weight, overweight, obesity and serve obesity using the body mass index (BMI kg/m2)5. Waist circumference alone, measured half way between the lowest point of rib cage and the iliac crest, is a better criterion, particularly for long-term follow-up.

Energy balance

The energy content of the diet must be appropriate to sustain growth in children, to prevent or to correct obesity in adults and to maintain body weight in those who are ill. The major determinant of energy requirement is basal metabolic rate which is itself principally determined by body mass, especially lean body mass, and  to lesser extend by age and gender; physically activity accounts for 10-50 % of energy needs. Walking for 3 miles/ hour to about 250 kcal/hour6.

Composition of diet

More active promotion of carbohydrate foods with a low glycemic index. Greater emphasis on the benefits of regular exercise.  Greater flexibility in the proportion of energy derived from carbohydrate and from mono-unsaturated fat. Mono-unsaturated fats are promoted as the main source of dietary fat because of their lower susceptibility to lipid peroxidation and consequently lower atherogenic potentional 7.

Weight management

Weight loss and stabilization is the major priority for those who are overweight. International weight loss of 11 % of initial body weight (from a mean of 100 kg down to 89 kg) is associated with a 25 % reduction in total mortality and a 28% reduction in cardiovascular and diabetes mortality9,10,11.

Carbohydrates

Dietary carbohydrates from cereals, breads, other grain products, legumes, vegetables, fruits, dairy products and added sugars should provide 50–60% of the individual’s energy requirements12. Both the source and the amount of carbohydrate consumed influence blood glucose and insulin responses13,14.The terms “simple” and “complex” should not be used to classify carbohydrates, because they do not help to determine the impact of carbohydrates on blood glucose levels 15,16. Factors that influence blood glucose are not predicted by chemical composition alone; food form, ingested particle size, starch structure and cooking methods may all influence the carbohydrate absorption rate from the small intestine and the resultant blood glucose response17.The glycemic index (GI) expresses the rise in blood glucose elicited by a carbohydrate food as a percentage of the rise in blood glucose that would occur if the same individual ingested an equal amount of carbohydrate from white bread or glucose 14,17. Increased use of low GI foods such as legumes, barley, pasta and whole intact grains (e.g. cracked wheat) may help improve blood glucose control and allow carbohydrate intake to be increased without raising serum triglycerides 18. The role of the GI in diabetes therapy is controversial. The GI is not endorsed by the American Diabetes Association 19, but it is recommended by the Diabetes Nutrition Study Group of the European Association for the Study of Diabetes10 and by the World Health Organization 14. There is concern that including GI information in nutrition teaching is   too complicated and limits food choices 11. Nevertheless, in people with newly diagnosed Type- 2 diabetes, there is evidence that nutrition education based on the GI is associated with higher carbohydrate, lower fat and higher fiber intakes as well as better blood glucose and lipid control — compared to those educated using traditional dietary advice 12.Epidemiological studies also suggest that use of low GI foods reduces the risk of developing Type- 2 diabetes 13,14. Extensive tables of the GI values of foods have been published 15.

Recommendations

• Carbohydrates should provide 50–60% of daily energy requirements.

• The amount and source of carbohydrate in meal planning should be considered.

• Including low GI foods may be helpful in optimizing blood glucose control.

Sugars

In the past, avoidance of sugar has been a major focus of nutritional advice for people with diabetes. However, research clearly shows that sugars are an acceptable part of a healthy diet for those with diabetes, particularly sugars obtained from fruits, vegetables and dairy products. Up to 10% of total daily energy requirements may consist of added sugars, such as table sugar and sugar-sweetened products, without impairing glycemic control in people with Type- 1 16 or Type- 2 17,18 diabetes. Foods containing sugars vary in nutritional value and physiological effects. For example, sucrose and orange juice have similar effects on blood glucose but contain different amounts of vitamins and minerals. Consuming whole fruits and fruit juices causes blood glucose concentrations to peaks lightly earlier but fall more quickly than consuming an equivalent carbohydrate portion of white bread. This results in a lower GI for fruits and fruit juices than bread 15,19. Because refined sucrose produces a lower blood glucose response than many refined starches, some sweetened breakfast cereals produce lower plasma glucose and insulin responses than equal carbohydrate portions of unsweetened cereals 20. Thus, undue avoidance of foods containing simple sugars is not necessary. Generally, however, intake of added fructose, sucrose or high-fructose corn syrup in excess of 10% of energy should be avoided, since evidence suggests that this may increase serum triglycerides and/or LDL cholesterol in susceptible individuals 21.

Recommendations

•Naturally occurring and added sugars should be included as part of the daily carbohydrate allowance and as part of a healthy eating plan.

•Most people with diabetes can include added sugars up to 10% of daily energy requirements without deleterious effects on blood glucose or lipid control.

Fibre

Daily soluble fibre intake of 5–10 g/d from oats, barley, legumes or purified fibre sources such as psyllium, pectin and guar, can reduce serum cholesterol by 5–10% 22,23.Purified soluble fibre sources reduce blood glucose responses and have been associated with improved blood glucose control 24. However, soluble fibre content alone is not a reliable indicator of the food’s metabolic effects. Research indicates that the insoluble fibre content of whole foods is more closely related to their GI than the soluble fibre content 25. This is consistent with data from epidemiological studies, which suggest that insoluble fibers from cereals may reduce the risk for coronary heart disease and Type -2 diabetes by up to 30% for each 10 g increment in intake 13,14,26. All Canadians, including people with diabetes, are advised to increase fibre intake from a variety of foods by following Canada ’s Food Guide to Healthy Eating .

Recommendations

•Total dietary fibre intake of at least 25–35 g/d from a variety of sources, as recommended by Canada ’s Food Guide to Healthy Eating, is advised for adults. For children, 5g/year of age is suggested as a guide.

•Including more foods and food combinations that combine cereal fibre with low GI may be helpful in optimizing health outcomes for people with diabetes or at risk for diabetes.

Protein

Current evidence indicates people with diabetes have similar protein requirements to those of the general population — about 0.86 g/kg per day 1. Although protein plays a role in stimulating insulin secretion 27,28, excessive intake should be avoided as it may contribute to the pathogenesis of diabetic nephropathy29.Some evidence suggests eating vegetable protein rather than animal protein is better for reducing serum cholesterol 30 and managing nephropathy 31,32.

Recommendations

•Protein intake should be at least 0.86 g/kg/day.

•Vegetable protein should be considered as an alternative to animal protein.

Fats

Numerous studies indicate high-fat diets can impair glucose tolerance and promote obesity, dyslipidemia and atherosclerotic heart disease. Research also shows these same metabolic abnormalities are reversed or improved by reducing saturated fat intake. Current recommendations on fat intake for the general population apply equally to people with diabetes: reduce saturated fats to 10% or less of total energy intake and cholesterol intake to 300 mg/d or less 33. Scientific debate continues over which alternative is preferable to saturated fat, polyunsaturated fat, monounsaturated fat or carbohydrate34,35.

Health Canada ’s nutrition guidelines are still considered appropriate for most people with diabetes. For adults who have normal lipid levels and maintain a reasonable weight, the guidelines recommend a daily fat intake≤30% of daily energy requirements, comprised of ≤10% saturated fat and ≤10% polyunsaturated fat, with the remainder coming from monounsaturated fat11.Research suggests monounsaturated fat (such as canola, olive and peanut oils) may have beneficial effects on triglycerides and glycemic control in some individuals with diabetes 36, but care must be taken to avoid weight gain. Omega-3 fatty acids, found in fish such as salmon and mackerel, may reduce serum triglycerides without impairing glycemic control 37. Although consuming large quantities of omega-3 fatty acids from natural foods is probably not practical for most, eating fish rich in omega-3 fatty acids at least once weekly is recommended. Conversely, ingesting trans-fatty acids that are commonly found in many manufactured foods should be limited. Produced by hydrogenating vegetable oils, the biological effects of trans-fatty acids are similar to those of saturated fat 38,39.

Recommendations

•Total fat should be limited to 30% of daily energy requirements.

•Saturated and polyunsaturated fats should each provide≤10% of daily energy requirements.

•Monounsaturated fats should be used where possible.

•Use of processed foods containing saturated fats and trans-fatty acids should be limited.

•Fish rich in omega-3 fatty acids should be recommended at least once weekly.

Alcohol

The metabolic effects of alcohol are complex and are influenced by many variables, e.g. the type and quantity of alcohol and the rate and ingestion, age and gender, individual variation, timing of consumption in relation to meals, exercise, nutritional site, ill health and non-diabetic medications40.

Recommendations

•People with diabetes should discuss alcohol use with their health care team.

•Alcohol consumption should be limited to 5% of total energy intake or 2 drinks per day, whichever is less.

•People with diabetes using insulin and/or insulin secretagogues, should eat a carbohydrate food when drinking alcohol to help avoid hypoglycemia.

•Abstinence from alcohol is advised during pregnancy and lactation.

•Individuals with medical conditions such as dyslipidemia, hypertension or liver impairment should avoid or restrict alcohol consumption.

Sample Exchange List

The exchange list is a tool to help plan healthy meals and snacks. To add variety to the diet, one can substitute certain foods for other foods in the same group5,6. Some examples are listed in Table- No.-3.

Table No- 3. Sample Exchange List

Sample Exchange List

Food Group

Food Group

Food Group

Fruit ( each serving contains about 15 g carbohydrate)

1 small or medium piece of fresh fruit

½ cup fruit juice, or canned or chopped fruit

Vegetable (each serving contains about 5 g) carbohydrate)

1 cup raw vegetable

½ cup cooked vegetables or vegetable juice

Starch (each serving contains about 15 g carbohydrate)

1 slice or ounce bread

½ cup pasta, cereal, starchy vegetable

Sugar, honey, molasses

1 teaspoon

4 g carbohydrates

Milk ( does not include cream, yogurt or cheese)

1 cup milk

12 g carbohydrates and 8 g proteins.

Other Aspects Of Dietary Advices

Insulin treatment

Insulin is anabolic and progressive weight gain can be a problem when glycemic control is tightened or when insulin replaces oral hypoglycemic agents in patients with Type-2 diabetes. Combined treatment with insulin and Metformin, which can reduce insulin dosage by improving insulin resistance and perhaps also by its anorectic effect, can be useful in those who are overweight 14,15

Oral hypoglycemic drugs

Metformin is probably the initial oral hypoglycemic drug of choice in overweight people with Type-2 diabetes who need more than just dietary management, because weight loss is more common than with sulphonylureas,  thiazolinidiones , and insulin and because the evidence of hypoglycemia is only slightly greater than in those treated by diet alone16.

Hypoglycemia

Glucose (10-20gm) is the preferred sugar for the immediate treatment of acute hypoglycemia because it dose not required digestion or metabolic. After recovery from oral hypoglycemia, a further 10-20 gm slower acting carbohydrate should be given12.

Alcohol

The metabolic effects of alcohol are complex and are influenced by many variables,e.g.the type and quantity of alcohol and the rate and ingestion, age and gender, individual variation, timing of consumption in relation to meals,exercise,nutritional site, ill health and non-diabetic medications40.

Diabetes and Exercise

Regular physical exercise improves insulin resistance and lipid profile and lowers blood pressure. It reduces mortality in type-1 diabetes and gives metabolic benefits in type-2 diabetis41.

Preparing the individual with diabetes for a safe and enjoyable physical   activity program is as important as physical activity itself. The young individual in good metabolic control can safely participate in most activities. The middle-aged and older individual with diabetes should be encouraged to be physically active. The aging process leads to a degeneration of muscles, ligaments, bones, and joints, and disuse and diabetes may exacerbate the problem. Before beginning any physical activity programme, the individual with diabetes should be screened thoroughly for any underlying complications.

For each 500 kcal/ week increment in energy expenditure, the age adjusted risk of developing Type-2 diabetes mellitus is reduced by 6 %; protective effect was strongest in people with highest Body mass index42. In contrast to the improvement in the skeletal muscle insulin sensitivity, glucose uptake by the heart is lower in healthy athletes than in sedentary subjects43.The diabetes prevention programme research group demonstrated that weight reduction of at least 7 % of initial body weight by low fat diet and exercise, such as brisk walking for at least 150 minutes per week, reduced the incidence of diabetes by 5 % 44 .

The American Diabetes Association has given exercise guidelines45for diabetic patients. These guidelines are: Exercise regularly, daily if possible; strenuous exertion is not necessary, even regular walking has metabolic benefits; Avoid exercise during periods of metabolic control; and moderate exercise should be part of the daily schedule, heavier exercise should be undertaken three times/week (systolic blood pressure should be kept < 200mm Hg), and exercise should include low intensity warming up and cooling down periods.

Conclusion

Nutrition management is a key component for the long term health and quality of life for people with diabetes. Attaining and maintaining blood glucose and lipid levels are near normal as possible and preventing and /or treating diabetes related complication and any concomitant conditions is vital to maintaining the physiological health of the people with diabetes. The role of Regular physical exercise improves insulin resistance, lipid profile and lowers blood pressure which helps in preventing the progression from insulin resistance to impaired glucose tolerance and overt hyperglycaemia has also been recognized.  

References

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About Authors:

V.G.Kuchake

V.G.Kuchake
Lecturer, Department of Clinical Pharmacy, R. C. Patel College of Pharmacy, Shirpur -425405, Dist: Dhule (M.S.), India.
Email- vitthalkuchake@yahoo.co.in; Phone- +91 9421750308; Fax – 02563- 251808
Author for Correspondence

D.A.Satpue

D.A.Satpue
R.C.Patel College of Pharmacy, Shirpur, Dist-Dhule, Maharashtra

R.D.Shimpi

R.D.Shimpi
R.C.Patel College of Pharmacy, Shirpur, Dist-Dhule, Maharashtra

P.H.Patil

P.H.Patil
R.C.Patel College of Pharmacy, Shirpur, Dist-Dhule, Maharashtra

P.V.Ingle

P.V.Ingle
R.C.Patel College of Pharmacy, Shirpur, Dist-Dhule, Maharashtra

S.J.Surana

S.J.Surana
R.C.Patel College of Pharmacy, Shirpur, Dist-Dhule, Maharashtra

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