Principles of Dietary Management of Diabetes

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Assessment The first step for planning an appropriate nutrition plan is a full assessment of the diabetic patient. Topics covered in the nutritional assessment are included in Table 1.

Individualization Individualization is a cardinal principle of medical nutrition therapy for diabetes, facilitating individual lifestyle and behavior changes that will lead to improved metabolic control. Since no one diet fits all, the standard, printed diabetic diet is inadequate. Rather, people with diabetes need to consult a person trained in dietetics, one able to develop and teach an individualized nutritional prescription. Table 2 indicates the range of goals that may need accommodation among different people with diabetes.

Developing the diabetes nutrition plan With the emphasis on individualization, the meal plan is driven by the diagnosis, pharmacologic treatment, lifestyle, and treatment goals. Important consideration is given to dietary preferences, socioeconomic factors, and the patient's ability to understand and implement instructions. Some patients will need instruction on fine points such as carbohydrate counting; others will benefit from the crudest of prescriptions, such as advice to stop buying concentrated sweets or frequenting fast-food restaurants.

Total energy intake The total energy requirement to maintain constant body weight may be calculated using the Harris-Benedict equation, taking into consideration the patient's activity level. The weight-maintaining requirement is then adjusted according to the therapeutic objective—to accomplish weight loss, maintenance of weight, or weight gain. Examples of how to make these calculations are shown in Table 3. Specific conditions such as childhood growth and development, pregnancy, malabsorption, or existing nutritional deficiencies are beyond the scope of this article.

Distribution of energy intake Distribution of carbohydrate, protein, and fat into the total energy target also depends on individual needs and therapeutic objectives. Most guidelines recommend that carbohydrate intake represent up to 50-60% of total energy, protein 15-20%, and fat 20-35%. Another approach groups carbohydrate and mono-unsaturated fats, recognizing that saturated fat should be restricted. This approach suggests that carbohydrate and monounsaturated fat should together account for 60-70% of energy intake.

Table 1 The Nutritional Assessment

Diet history/nutrition information—can be obtained using dietary assessment tools such as 24-h recalls, food records, food frequency questionnaires, or dietary intake interviews

Meal patterns: Usual distribution of meals and snacks throughout the day, including variations from day to day, weekdays versus weekends, skipped meals, and external influences such as work, school, travel, vacations, and holidays Food choices: Types and amounts of foods consumed at meals and snacks Nutritional adequacy: Dietary excess or deficiency; also considers overall dietary balance

Beliefs or misconceptions: Fears or misconceptions of a 'strict' diabetic diet or about certain foods; can also include certain religious beliefs or ethnic beliefs about foods Personal information

Age, gender, socioeconomic status, ethnicity, occupation, education, and literacy level Ability and willingness to change (stages of change)

Emotional and mental state if distressed by a new diagnosis of diabetes or other health complications related to diabetes

External stressors that may interfere with compliance

Smoking or drug history

Exercise or activity schedule

Clinical information

Type of diabetes and treatment, such as with insulin, oral hypoglycemic drugs, or diet alone Physical activity, body weight, and blood pressure Lab results, A1C, and lipid profile Other medical conditions

Education

Diabetes education should be an ongoing interactive process between patient and health professional and cannot be given in a single session

Individualism is key to successful nutritional management

Most important aspect is to match the type and level of information to individual needs and abilities Important to provide written information summarizing key messages that patient can take home and refer to later

Follow-up and monitoring progress

Follow-up and review of progress essential

Frequency will depend on type of treatment, glycemic control, and patient's ability to meet goals

Consider if specific dietary targets have been achieved and/or reasons why targets have not been met and what barriers need to be overcome

Consider acceptability of dietary changes and impact on patient's quality of life

Clinical picture should examine glycemic control, lipid profiles, weight changes, and blood pressure

Adapted from Conner H et al. Nutrition Subcommittee of the Diabetes Care Advisory Committee of Diabetes UK (2003) The implementation of nutritional advice for people with diabetes. Diabetic Medicine 20(10): 786-807.

Even these broad goals are the subject of considerable controversy, with some experts recommending a lower carbohydrate intake and higher fat intake, particularly of monounsaturates. A common mistake is for the patients to think they have a diet low in both carbohydrate and fat without being low in total energy intake. It is unlikely that a person's dietary protein intake will exceed 15-30% of all energy consumed; therefore, 70-85% of intake is generally distributed between fat and carbohydrate.

Distribution of energy intake throughout the day may vary, too. Insulin-requiring diabetic patients, for example, may need a more evenly distributed energy intake, even including a bedtime snack to avoid hypoglycemia. This would not necessarily be indicated for someone with type 2 diabetes trying to lose weight, although weight-reducing diets are generally considered more effective if the total energy intake is spread more or less evenly throughout the day so that the patient does not build up a hunger and gorge late in the day. One report of Muslims observing daytime fasting during Ramadan found that more than half did not lose weight, suggesting a major redistribution of caloric intake to nighttime hours. A significant increase in hypoglycemia occurred during the days of Ramadan. Reduced energy intake for prolonged periods is most dangerous for patients taking insulin, but it may also be significant in those taking oral hypoglycemic agents such as sulfonylureas.

The utility of exchange lists There has been a shift on the part of patients and some health professionals away from the use of formal 'exchange lists' for meal planning. The traditional exchanges estimate not only carbohydrate but also certain proportions of fat and protein in similar foods. Food labels make the calculation of specific fat and carbohydrate content easier. The trend, therefore, is to emphasize the carbohydrate and fat awareness by teaching them directly rather than lumping mixed foods together in exchanges.

Gastroparesis An extremely difficult challenge is posed by the patient with diabetic gastroparesis. This

Table 2 Cases illustrating the variable clinical issues affecting people with diabetes and the resulting diversity of their nutritional needs

Type of diabetes

Type 1

Type 1

Type 2

Type 2

Age (years)

14

38

56

76

Duration of DM (years)

6

26

6

6

BMI

18

23

27

34

Physical activity

Vigorous

Moderate

Mild

Minimal

Prone to hypoglycemia

Yes

Yes

Yes

No

Prone to hyperglycemia

Yes

Yes

Yes

Yes

Blood lipids

Normal

Normal

High LDL cholesterol

High TG, Low HDL

Blood pressure

Normal

High

Normal

High

Dietary preferences

Likes sweets, snacks

Healthy, little carb awareness

Spicy foods, irregular meals

Fried foods, sweets

Pharmacologic therapy

Multiple-dose insulin

Multiple-dose insulin

Oral agents plus insulin

Oral agents

Life expectancy without

66 years more

44 years more

26 years more

8years more

diabetes

Major nutritional

Adequate caloric

Stabilize carb intake,

Mildly hypocaloric

Low salt, high vegetable

considerations

intake for growth (see Table 3)

count carbs

(see Table 3)

for hypertension (DASH diet)

Recognize carb

Low salt, high vegetable

Hypolidemic

Hypolipemic diet

portions, regularize

for hypertension

(low saturated fat)

(low saturated fat)

carb intake

(DASH diet)

Avoid excess

Regularity of meals,

Moderately hypocaloric

concentrated sweets

consistency of carb and fat intake

Learn factors causing

Control of dietary carb,

hypoglycemia

especially high-energy concentrated sweets

Healthy heart diet

BMI, body mass index; DM, diabetes mellitus; HDL, high-density lipoprotein; LDL, low-density lipoprotein.

Healthy heart diet

BMI, body mass index; DM, diabetes mellitus; HDL, high-density lipoprotein; LDL, low-density lipoprotein.

condition, a severe autonomic neuropathy reducing gastric motility and gastric emptying time, is often difficult to diagnose by standardized testing, such as gastric emptying studies. Gastroparesis typically causes early satiety, nausea, vomiting, and abdominal pain, with markedly variable food ingestion. Along with pharma-cologic management and good glycemic control, the dietary prescription should include small, frequent feeding as tolerated, but the condition can progress to the point that any oral intake is difficult, and tube feeding or a gastrostomy is required. Fortunately, diabetic gas-troparesis tends to wax and wane in severity.

Glycemic control and weight gain Research studies have repeatedly found that when a patient with poor glycemic control achieves good glycemic control, there is a strong, almost inevitable, tendency to gain weight. This may simply be due to the retention of energy that was previously lost in the urine as glucosuria, but the patient should be warned of the likelihood of gaining weight when poor diabetic control is adequately treated. As for quitting smoking, the health benefit of glycemic control far outweighs the risk of weight gain.

Nutritional instruction To achieve a stable, healthy diet, the following key educational issues must be considered (adapted from Franz M, Krosnick A, Maschak-Carey BJ et al. (1986) Goals for Diabetes Education. Chicago: American Diabetes Association):

Survival skills Relation of food to insulin and activity Importance of good nutrition in the control of blood glucose and lipid levels Necessity of maintaining normal weight Types and amounts of food in meal plan Modification of food intake during brief illnesses In-depth counseling Meal planning

Types of nutrients, their functions, relation to insulin, and effect on blood glucose and lipid levels Caloric level of meal plan and percentages of carbohydrate, protein, and fat Food sources of fiber

Importance of reducing total fat, saturated fat, and cholesterol in the diet Relation of sodium to hypertension Proper serving sizes

Changes in food intake based on activity level

Eating out and special occasions

Label reading and grocery shopping

Use of sweeteners, alcohol, and 'dietetic' foods

Food modifications for other disorders

Incorporation of favorite recipes

Table 3 Sample calculations of energy requirement in differing circumstances using the Harris-Benedict formula to determine caloric requirements for children and adults

Caloric requirements = basal metabolic rate x activity factor x injury factor

Basal metabolic rate (BMR)

For men: BMR = 66 + [13.7 x wt (kg)] + [5 x ht (cm)] - [6.8 x age (years)]

For women: BMR = 655 + [9.6 x wt (kg) + [1.8 x ht (cm)] -[4.7 x age (years)]

Multiply by the following factors: Activity factors

1. Sedentary (little or no exercise): BMR x 1.2

2. Lightly active (light exercise/sports 1-3 days/week): BMR x 1.375

3. Moderately active (moderate exercise/sports 3-5days/week): BMR x 1.55

4. Very active (hard exercise/sports 6-7 days/week): BMR x 1.725

5. Extra active (very hard daily exercise/sports and physical job or 2Xday training): BMR x 1.9

Injury factors (not used for healthy individuals)

1. Generalized stress: 1.1-1.2

For weight loss, use the above calculated formula for caloric requirements and subtract by 500calories: Caloric requirements - 500calories/day = modified calorie requirements

This is for a recommended 0.5-1 pound of weight loss per week

Special aspects: Type 2 diabetes There are two pathophysiologic mechanisms underlying type 2 diabetes: The body's cells are resistant to the action of insulin, and the pancreas is unable to secrete enough insulin to overcome that resistance. Although it is not entirely clear which of these processes occurs first, and although the balance of the two may vary from case to case, the most common cause of insulin resistance is overweight or obesity. Unfortunately, much evidence has shown that people of Asian ethnicity are especially prone to obesity-related type 2 diabetes even when their body weight, by Western standards, is normal. Japanese Americans, for example, show an increase risk of diabetes if their body mass index (BMI) increases to only 24. This excessive risk with even mild degrees of excess body weight may explain the marked rise in diabetes when previously undernourished populations begin to have adequate nutrition. In this sense, diabetes is a disease of prosperity.

Major objectives Approximately 95% of all people with diabetes have type 2, and the major increase in the prevalence of diabetes in recent years is almost entirely accounted for by increase in body weight. It cannot be overemphasized that medical nutrition therapy of type 2 diabetes should address normalization of body weight. In most cases, the focus is on reducing dietary intake of saturated fat and increasing energy expenditure through exercise. By reducing body weight, insulin resistance is reduced, making the patient's endogenous insulin more effective. Given that approximately 85% of people with type 2 diabetes die of cardiovascular cause, the second emphasis of medical nutrition therapy for type 2 diabetics must address dyslipidemia and blood pressure.

Hypoenergetic diets are remarkably effective in controlling hyperglycemia. Indeed, blood glucose levels improve, often dramatically, as soon as a low-energy diet is started, apparently by reducing hepatic glucose production. The correction of insulin resistance is more closely correlated with actual weight loss, which takes much longer. The best strategy for accomplishing and maintaining weight loss is unclear and may vary from person to person depending on the different factors involved, such as willingness to change and other lifestyle behaviors. Dosages of antidiabetic drugs may have to be altered as the person loses weight.

Persistent insulin resistance in type 2 diabetes, together with deteriorating pancreatic insulin secretion over time, means that many people with type 2 diabetes eventually require exogenous insulin therapy. This does not change the diagnosis to type 1 diabetes, which is a disease of entirely different pathogenesis. Because of the insulin resistance, people with type 2 diabetes taking insulin often need high doses, often 50-100 units per day or higher. Insulin requirements will predictably be less when energy intake is reduced.

Recently, in Western societies, many overweight teenagers have presented with type 2 diabetes. It can no longer be assumed that children with diabetes have type 1. Indeed, some reports find that half of all teenagers with diabetes have type 2, a marked shift from prior years. Furthermore, nutrition therapy for children with diabetes must be designed with a clear understanding of what type of diabetes they have. In cases of obesity-related type 2, calorie restriction may be indicated.

Coexisting risk factors Obesity, dyslipidemia, and hypertension are especially prevalent in type 2 diabetes. The constellation of comorbidities has been called metabolic syndrome, 'syndrome X,' or the insulin resistance syndrome (Table 4), and some investigators believe that insulin resistance is the primary lesion. Whatever the pathophysiologic mechanisms, it is clear that dyslipidemia and hypertension must be sought and aggressively treated if

Table 4 The Metabolic Syndrome

Three or more of the following components: Central obesity as measured by waist circumference Men: >102cm (40in.) Women: >88cm (35 in.) Fasting blood triglycerides >1.69 mmol/l (150mg/dl) Blood HDL cholesterol Men: <1.04mmol/l (40mg/dl) Women: <1.29mmol/l (50mg/dl) Blood pressure >130/85 mmHg Fasting glucose >6.1 mmol/l (110mg/dl)

present. In fact, most evidence suggests that the management of coexisting risk factors, particularly hypertension, dyslipidemia, and smoking, is more important than the treatment of hyperglycemia in preventing morbidity and mortality.

Special aspects: Type 1 diabetes With type 1 diabetes, there is essentially no endogenous insulin secretion, due to autoimmune destruction of the insulin-producing beta cells of the pancreas. This lack of an essential hormone for life means that insulin must be injected, often multiple times daily. Furthermore, the replacement of a very finely tuned normal insulin secretory mechanism, which provides insulin precisely 'on demand,' cannot be well reproduced by injections, explaining the glycemic lability of type 1 diabetes.

Major objectives Generally, the treatment objective in type 1 diabetes is stabilization of glycemic control in an acceptable range, control of other risk factors, and thus avoidance of long-term complications. This requires close attention not only to diet but also to its interrelationships with insulin dose and timing, activity, stress, and other life factors. In fact, despite the best efforts, almost all people with type 1 diabetes are prone to wide swings of blood glucose, sometimes from 2.8 to 17 mmol/l (50-300 mg/dl) or more during a day.

To control the intrinsic 'brittleness' of type 1 diabetes, the individual needs to learn to stabilize dietary intake, making it as reproducible as possible. If carbohydrate, in particular, varies significantly from day to day and meal to meal, the person must learn to adjust insulin doses to match the changed intake. Carbohydrate counting helps stabilization of the diet or adjustment in insulin doses. It is useful for the nutritionist to understand the various insulin regimens that people with type 2 diabetes are given. Several different typical regimens, with comments on the dietary implications, are shown in Figure 1.

In addition to carbohydrate awareness, dietary fat intake should be taken into consideration. Dietary fat is often the main determinant of serum lipids and contributes significantly to total energy intake and thus body weight. It also delays gastric emptying, prolonging the glycemic response to dietary carbohydrate.

Very few people continue to measure and weigh foods, but weighing is a useful tool during the instruction phase. Ultimately, people with type 1 diabetes should become proficient in estimating the carbohydrate content of food so that their food selection becomes second nature.

Energy intake distribution will depend on the type of insulin, the number of injections, and the glycemic targets (very tight blood glucose control or not as tight). Often, small changes in food ingestion can make a significant difference. If, for example, a patient tends to develop hypoglycemia at approximately noon, the skillful dietitian can either emphasize the necessity of eating lunch regularly before noon or suggest the patient consume some of the lunch carbohydrates as an 11 am snack. These changes may eliminate the need to change insulin dose.

Especially with intensive insulin therapy (three or four daily injections or an external insulin pump), there is some flexibility in the timing of the meals but also a need for more accurate assessment of meal content. Some patients will learn their own ratio of grams of carbohydrate to insulin dose necessary to maintain blood glucose in a good range.

Eating disorders pose a serious problem to the management of type 1 diabetes. Presumably because people with diabetes are often diet conscious, the prevalence of eating disorders is surprisingly high among teenagers with diabetes. The problem is especially dangerous because young people may skip insulin injections in order to induce glucosuria, a sort of 'metabolic purging.' These conditions clearly require prompt professional help.

Growth and development The total daily energy intake of a person with type 1 diabetes should be calculated to maintain normal growth and development in a child and normal weight in an adult. Examples of these calculations are provided in Table 3. Since most people with type 1 diabetes are not overweight, most do not need low-energy diets. Indeed, underfeeding is a poor way to maintain blood glucose control. The energy needed to establish and maintain normal weight should be matched with the insulin needed to control glycemia. There is no need for a thin or normal-weight person with type 1 diabetes to be perpetually hungry.

Special aspects of dietary management of other types of diabetes Other types of diabetes include those with relatively well-recognized etiologies, such as t t t t !:-1--1

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