Diabetes is a chronic disease in which food is not properly absorbed in the body to be used as energy. This results in high levels of sugar in the blood. During the normal process of digestion, food is consumed and broken down into small sugar particles called glucose. The glucose enters the blood stream and is moved into the body’s cells, where it can be used as energy. Insulin is a hormone that is produced by the pancreas. People with diabetes have too little insulin production, their body is unable to use insulin properly (insulin resistance), or both. This does not allow glucose to be moved into the body’s cells, which results high levels of glucose in the bloodstream.
MEDICAL NUTRITION THERAPY
The objective of nutrition therapy is to help people with diabetes learn how to make appropriate food choices that will have a positive impact on blood glucose, lipid levels and blood pressure. Once made, these choices can help diabetes achieve optimum metabolic control that may delay or prevent diabetes related complications and improve overall health.
The goals of medical nutrition therapy are achieve or maintained normal or close to normal blood glucose level, lipid and lipoprotein profile and blood pressure. The American Diabetic Association develops the nutrition care process.
This the frame works for the delivery of medical nutrition therapy.
Nutrition Care process consist of following elements-
1. Nutrition assessment
2. Nutrition diagnosis
3. Nutrition intervention
4. Nutrition monitoring and evaluation
The nutrition assessment is the initial step in developing an individualized nutrition education and meal plan. it is the critical step because the treatment and counseling is entirely depend on this assessment much of the information can be gleaned from medical record while other information should be option from the patient and his family.
The first part of the nutrition assessment is obtained from medical record and analysis of the data.
- Height and weight
- Desirable body weight
- Daily energy need and BMI
- Medical and weight history
- Laboratory values
- Current level of diabetes control
The second part of the assessment also serves to establish a rapport between the person and the health care provider. It allows to learn the interventions that may be most acceptable to the person being counselled. This assessment should whenever possible done with person directly and relying on family members to give the information.
The first step in the assessment of the body weight is the determination of desirable body weight. There are many different methods of assessing an individual body weight. The common method is described below
Formula to calculate desirable body weight
For Men: Ht in Cms – 100
For women: Ht in Cms -105
BODY MASS INDEX
The second is the determination of BMI. This the number calculated from a person’s weight and height. BMI provides a reliable indicator for most people and iS used to screen for weight categories that may lead to health problems. (see the table below). It is a indicator of the weight status of a person. It can be calculated as follows:
STEP 1: MEASURE THE WEIGHT IN KG
STEP 2: MEASURE HEIGHT IN METERS
STEP 3: CALCULATE BMI BY THE FORMULA
BMI= Weight (in kgs).
(Height in meters)2
|BMI CUTOFFS FOR ASIANS AND INDIANS|
|Normal weight||18.5 – 22.9|
|Overweight||23 – 24.9|
The third is to determination of body shape. Body shape has been found to be an important when predicting person risk of cardiovascular disease and metabolic condition. Abdominal fat is an important risk masker for cardiovascular disease and type 2 diabetes. The waist hip ratio can be used classify people either pear or apple shaped. Refer book 101. People with pear shaped body have a low WHR and are at a low risk of cardiovascular complications compare a people with apple shaped body. Generally female have pear shaped body and male have apple shaped body. WHR is also called abdominal gluteal ratio (AGR).
|Wait to Hip Ratio|
|Male||Female||Health Risk based on WHR|
|0.95 or below||0.80 or below||Low Risk|
|0.96 to 1.0||0.81 – 0.85||Moderate Risk|
|1.0 +||0.85 +||High Risk|
MEDICAL NUTRITION THERAPY EMPHASIS A BALANCED DIET
A balanced diet is defined as one that contains variety of food from both the micronutrient and macronutrients group. Macronutrients known as such because the body needs more of this included proteins, carbohydrates and fats. These nutrients are
- Oxidized in the body to provide energy
- Needed for reproduction
- Essential for cell repair and growth
Micronutrient – required in smaller amount – included vitamins and minerals.
Adequate fluid are also essential for bodily function. The component of a balanced diet differs according to age, gender, physical activity etc.
Once the nutritional assessment has been completed the health care should have enough information to determine the nutritional status and needs of the person with diabetes. This will help to determine the specific eating eating behaviors that need to be modified.
The person with diabetes and the health care provider can work together to change goals in area of nutrition and eating habits and priorities them. Goals should be realistic; patient centered and may be both short- term and long term.
This step involves the planning and implementation of educational activities and counseling needed to modify the person’s nutritional eating habits or behaviors. The implementation will involve the selection of a meal planning method based on nutritional assessment and patient centered goals. The health care provider at this step in the process also include being a counselor and cope with its effects.
MEAL PLANNING METHOD
There are 5 common methods of meal planning uses for people with diabetes. Each one is described below:
The Food pyramid is a visual that helps explain the kinds and amount of food that should be eaten. The base of the pyramid consists of the foods that should be eaten more frequently. As one goes up the side of the pyramid, the person eat fewer servings of the foods indicated, eating the least amounts of the foods at the top of the pyramid. The foods at the top of the pyramid tend to be calorie dense and should be eaten sparingly.
The cereal group forms the base of the pyramid and a large portion of the meal consists of foods taken from this group of foods. Each serving in the cereal group contains 15g of carbohydrates, 3g of proteins, a trace of fat and gives about 80 calories. The maximum number of servings per day should come from foods in this group preferably those made with whole grains.
This comes above the base of the pyramid and these are rich in essential vitamins, minerals, antioxidant and fiber. Each serving in this group contains 5g of carbohydrates, 2g of proteins and provide approximately 28 calories.
PULSES AND DALS
Each serving in this group contains 12g of carbohydrates, 6g of proteins and 1g of fat and provides approximately 80 calories. Each serving in the group is about 25 g by weight if uncooked and about 1 cup cooked( thin, watery) or 1/2 cup cooked (thick).
MILK AND MILK-BASED PRODUCTS
Each serving of skim milk and skim milk based foods contains 12 g of carbohydrate, 8 g of protein, and provides 80 calories. Each serving of whole milk and whole milk based foods contains 12 g of carbohydrate, 8 g of protein, provides 8 g of fat and provides 150 calories.
This food groups comes near the apex of the Indian food pyramid. Each serving in this group contains 15g of carbohydrates and provides 60 calories.
FATS AND OILS
This group comes at the apex of the Indian food pyramid. Items in this group should be used sparingly. Each serving in the fats and oils group contains 5 g of fat and provides 45 calories.
One serving is a teaspoon of cooking oil. Even sugar rich products come under this category s both at concentrated sources of energy. Only a small amount of food from this group is necessary for a well balanced meal.
The exact number of servings from each group depends on the person’s diabetes goals, nutritional requirements, lifestyle and good preferences.
Bran can be added to wheat atta(1 teaspoon to 100g) to make nourishing chapattis
Use brown rice , it has more flavour and fibre then white rice
Blended atta can also be used( 7kg wheat +1.5kg barley +1.5 kg soybean +1/2kg channa)
Use of white bread , naan, roomali roti and other maida preparations should be limited.
Fruits and vegetables
Choose fresh fruits and vegetables
Enjoy whole fruits than rather than juices
Use herbs and spices. Season foods with cinnamon, cloves and bay leaves
Limit dried fruits as they are a concentrated source of carbohydrate and calories.
Use skimmed milk or double toned instead of whole milk for making tea, coffee, puddings etc.
Look for low fat yoghurt and cheese.
Use egg whites instead of whole eggs. Two egg whites can replace one whole egg.
Select more chicken and fish based dishes over mutton, pork and beef.
Use low fat spreads such as cottage cheese full skimmed milk or fat free fruit preserves instead of butter cheese or mayonnaise.
|Suggested Intake of Food Groups|
|Cereals||6 servings per day|
|Pulses||2 servings per day|
|Vegetables||3 servings per day|
|Fruits||2 servings per day|
|Dairy products||2-3 servings per day|
|Meat & its products||1-2 servings per day (preferably fish or chicken as second choice)|
|Fats & Oils||< 3 teaspoons per day|
|Sweets||Some recommendation allowed to 10% of daily calories from sucrose|
The Plate Method
- Avoid all sugar in drinks. Drink Diet Soda, Crystal Light, or Flavored Water.
- Do not add sugar, honey or brown sugar. Use Equal, Splenda or Sweet n Low.
- Eat 3 balanced meals a day, 4-5 hours apart.
- Add a protein food to your snack.
- Eat low fat to protect your heart; eat less fried foods, fast foods.
- Eat less salt to help with blood pressure; less fast food and packaged foods
Carbohydrate is fuel for our body. You need to eat some at each meal and snack.
Carbohydrate turns to sugar or glucose in our bloodstream.
Carbohydrate is found in sweets, snacks, milk, fruit, starch and starchy veggies.
One serving = 15 grams of Carbohydrate.
Men can have 4-5 Carbohydrate servings per meal.
Women can have 3-4 Carbohydrate servings per meal
Snacks can have between 1-2 Carbohydrates.
ESTIMATING PORTION SIZES WITH HANDS
It is difficult sometimes to measure foods and know exactly the quantity of food that is being consumed. People can use their hands to estimate the correct portion size of food that they should eat.
The signal system is a useful aid to educate large numbers of people. The signal system is based on traffic light system
|Red Zone||Yellow Zone||Green Zone|
|This food rich in fat an in refined carbohydrates/ sugars and have high glycemic index or are low in fiber. They should be eaten in very limited quantities.||This food should be eaten in a moderation since they may have high glycemic index, are low in fiber content, or have moderate amount of fat||This food is healthy choices because they have low glycemic index, are high in fiber content and low in fat. However, foods in the green zone should only be eaten in the recommended amount|
BENEFITS OF FIBRE
There has been a growing interest in the role played by dietary fibres in the management of diabetes. Fibres are shown to –
- Reduce the rise of blood glucose level following a meal
- Stabilize the post-prandial swings in the blood glucose levels
- Decrease the serum cholesterol and triglyceride levels
- Make people feel full after a meal so that they may eat less
Fibres can be classified into
- Soluble Fibres
- Insoluble Fibres
Soluble Fibre is highly viscous and may delay the gastric empting of ingested foods into the small intestine resulting in a sensation of fullness and slowing the raise of blood glucose after a meal.
Insoluble Fibre retains water, resulting in softer and bulkier stools and increases fecal bulk.
The recommendation intake for total fibre in foods is 38 g per day for men and 25 g per day for woman.
IMPORTANCE OF FAT IN DIET
Fat is a concentrated source of energy. 1 gm of fat provides 9 calories of energy. It is an essential nutrient and plays several vital roles:
- Provides oil for the skin
- Regulates body functions by forming hormones
- Insulates and protects internal organs
- Carries fat-soluble vitamins throughout the body
- Helps repair damaged tissue and helps to fight infections.
The energy derived total fat intake for an individual should be between 15-20% of the total energy intake. A people with diabetes have an increased risk of atherosclerosis control of fact intake becomes more vital.
Important distinctions are made between the different types of fat in the diet. They are:
- Polyunsaturated fats: They help to reduce LDL cholesterol and also lowers level of HDL cholesterol. Eg. Safflower oil, sunflower oil and corn oil.
- Saturate fats: They can significantly raise the blood cholesterol levels, especially the level of LDL cholesterol. Eg. Red meats, butter, cheese, ghee, whole milk, cream, lard.
- Trans -fatty acids: They lower HDL cholesterol and raise LDL cholesterol. Baked products, biscuits and cakes.
- Mono unsaturated fats: They should generally be preferred as they enhance cardio-vascular health and help lower LDL cholesterol. Olive oil, canola oil, groundnut oil, rape seed oil, mustard oil and sesame oil.
EFFECTS OF ESSENTIAL FATTY ACIDS
There is another kind of fat called essential fatty acids. These unsaturated fats, including Omega-3 & Omega -6 fats, make the cell membrane more flexible, lower blood pressure and cholesterol, and reduce mortality from heart disease. They are also required for the production of certain hormones that are essential for blood clotting, blood pressure control, eye and brain function.
Cold water fish such as salmon, oily fish, soya bean oil, rape seed oil, sesame oil, wheat, bajra, black gram, cow pea, chick pea, rajmah, soya, green leafy, fenugreek, mustard, walnut, flaxseed are rich in Omega-3 fatty acids. Omega-6 fatty acids are found in grains such as corn, along with corn oil, safflower oil, sun flower oil, soya bean oil, cotton seed oil and in the meat of animals that have been fattened or grain.
ROLE OF PROTEINS
Proteins are an important constituent of tissues and cells in the body. 1 gm of protein provide 4 calories of energy. They have different functions such as:
- Provide the body with energy
- Supply the body with building material for growth and repair.
- Reduction of hormones, antibodies, enzymes and tissues.
Proteins are broken down into amino acids – the building blocks of body tissue. Amino acids that cannot be synthesized in the body and are supplied in the diet are called essential amino acids. Proteins come from both animal and plant sources. Animal sources