Diabetes is a chronic disease that requires a holistic approach to care to prevent both acute and long-term complications.
Nutrition management for diabetic patients has been evolving for 100 years as the pathophysiological basis of complications from diabetes becomes more explicit.
Medical nutrition therapy is extremely important for diabetic and prediabetic patients so that adequate glycemic control can be achieved. Face-to-face interviews with a dietician who is familiar with diabetic nutrition are preferred, as has been shown in studies carried out in Pakistan and Hungary, which have shown the usefulness of a dietician in improving dietary adherence.
Nutrition counseling should be sensitive to the patient’s personal needs and how much effort the patient is willing to put in to make the diet change appropriate.
Medical nutrition therapy for diabetics can be divided into dietary interventions and physical activity. Lifestyle and dietary modifications form the basis of therapy in patients with type 2 diabetes ( insulin resistance ).
In patients with type 1 diabetes, who have insulin deficiency, a balance between insulin and nutritional needs must be achieved for optimal glycemic control
Nutrition for diabetic patients can be further divided into prevention and ongoing management of glycemic control. Prevention is more for individuals at risk of developing diabetes and for type 2 diabetic patients than for patients who have already developed complications, in order to prevent further progression.
The objectives of preventive nutrition are as follows:
- Primary prevention. Identification of the high-risk population ( body mass index (BMI)> 25), obesity or prediabetic state, and implementation of diet and lifestyle changes.
- Secondary prevention. Use of nutrition as a therapeutic modality to obtain euglycemia in diabetic patients.
- Tertiary prevention. Nutrition is a tool for managing the macrovascular and microvascular complications of diabetes and for postponing morbidity and mortality.
Food groups include macronutrients and micronutrients. There is no optimal dietary mix of macronutrients that can be prescribed to the entire diabetic population. Dietary needs must be individualized.
Reduction in fat intake ( saturated fat, trans-fat, cholesterol ) in diabetic patients is intended to decrease the risk of cardiovascular disease by reducing plasma cholesterol and low-density lipoprotein (LDL) cholesterol levels.
Low-carbohydrate, low-fat diets used to achieve initial weight loss are effective in the short term (approximately 1 year) and require monitoring with lipid profile and kidney function tests. Low-carb diets (20-120g / day) bring the added benefit of a favorable lipid profile when compared to low-fat diets. Low-carbohydrate diets have also been noted to decrease fasting plasma glucose values by approximately 21-28 mg / dL.
The so-called Mediterranean diet may be an option. A study in which subjects (N = 322) were randomized to 1 of 3 diets (the Mediterranean, limited calories, low fat, limited calories; low carbohydrates, unrestricted calories) found that at a 2-year follow-up, the 36 diabetic subjects assigned to the Mediterranean diet had more favorable fasting plasma insulin and glucose levels compared to those assigned to the low-fat diet.
For patients on insulin therapy or oral hypoglycemia, being on a restrictive diet requires dosage adjustment to prevent hypoglycemia.
The carbohydrate choices in diabetes are as follows:
- Carbohydrates are necessary for energy, for some vitamins, and fibers, for dietary palatability, and as an important postprandial glucose regulator;
- The recommended daily amount of carbohydrates is 130 g / d;
- The type of carbohydrates consumed (starch, amylose, amylopectin) is reflected in the postprandial glucose values.
Consumption of low glycemic index foods can result in a 0.4% drop in hemoglobin A1C compared to high glycemic index foods, bloating and a restrictive diet limit the use of this type of diet.
Non-nutritive sweeteners have fewer calories compared to the regular sucrose used in table sugar but have not been shown to lower blood sugar, accelerate weight loss, or cause weight gain.
Dietary recommendations for fats in diabetes are as follows:
- Total dietary cholesterol consumption of less than 22 mg / d;
- Consumption of saturated fat is 7% of the person’s daily consumption;
- Multiple servings of non-fried fish per week are recommended as a source of omega-3 fatty acids, which are postulated to reduce cardiovascular complications.
The consumption of plant sterols is recommended to block the intestinal absorption of cholesterol and decrease the total percentage of plasma LDL cholesterol, if the consumption is around 2 g / d
The recommendations for protein in diabetes are a good quality diet with plenty of protein is recommended. This measure can help in achieving weight loss and blood glucose control.
In addition to macronutrients, micronutrients are an important component of a balanced diet. Uncontrolled dietary patients are usually micronutrient deficient due to poor dietary choices. Physicians should encourage getting their daily needs from a healthy, balanced diet rather than multivitamin supplementation. If this cannot be achieved, then a daily multivitamin is acceptable. Zinc, copper, and chromium have been studied but play no role in achieving tight glycemic control.
Much interest has been put into the role of antioxidants in diabetes, as diabetes has been noted to be a state of oxidative stress. Flaxseed has been shown in experiments to decrease inflammatory markers in type 2 diabetic patients, but there are no specific and reliable recommendations.
Vitamin E in combination with other antioxidants has a tendency to do more harm than good if taken for too long. Patients should always be asked about their use of herbal supplements to treat their type 2 diabetes, as herbal supplements can interact with other medications and produce unexpected adverse effects. To date, there is insufficient evidence that herbal supplements help manage diabetes.
Adults with diabetes who choose to indulge in alcohol should be warned about the risk of nocturnal hypoglycemia if consumed in the evening without food. It has been recommended that men limit their consumption to 2 drinks per day, while for women 1 drink per day is suggested. An alcoholic beverage is defined as a 12-ounce serving of beer, (one ounce is nearly thirty grams), a 5-ounce serving of wine, and a 1-5-ounce serving of distilled alcohol. Complete abstinence from alcohol should be advised for people who have severe peripheral neuropathy and hypertriglyceridemia.
Physical activity of 150 minutes per week is especially recommended for type 2 diabetic patients, as it causes moderate weight loss and increased insulin sensitivity. If vigorous activity is performed then the duration time is 125 minutes per week, with no more than 2 consecutive days without training.
The National Institute of Heart Blood Lungs, using data from the Public Health and Nutrition Examination Research (NHANES), defines overweight people as having a BMI of 25-29.9 kg / m2 and obese having a BMI greater than 30 kg / m2.
For patients with type 2 diabetes with a BMI greater than 35 kg / m2, a greater benefit was noted in undergoing bariatric surgery compared to continuous medical therapy compared to glucose control and weight loss. Weight loss drugs in the initial 5-10% of weight loss are recommended for patients with established diabetes who have a BMI greater than 27 kg / m. ”
Studies have shown that a high BMI with increased waist circumference (an indicator of visceral fat) is a predictor of the development of type 2 diabetes and cardiovascular disease. In both long- and short-term studies evaluating weight loss and its resulting effect on a drop in hemoglobin A1C, however, the results were not consistent.
Yoga has been suggested as an alternative for severe diabetic patients who may not be able to participate in strenuous activity. Malhotra and others undertook a study of 20 patients in Dehli, India, and concluded that yoga has a beneficial effect on glucose control as well as promoting weight loss.
A current trial, Look AHEAD (Action for Health in Diabetes), was designed to evaluate the results of long-term weight loss on blood sugar and the development of cardiovascular disease. For type 1 diabetic patients with macrovascular or microvascular complications, a personalized exercise program is warranted as strenuous exercise can cause complications.
If patients have active proliferative diabetic retinopathy, they should be advised to refrain from strenuous exercise or Valsalva maneuvers, as they can precipitate vitreous hemorrhage. Patients with microalbuminuria (> 20 mg/min albumin secretion) or overt proteinuria (> 200 mg/min protein secretion) should not engage in high-intensity physical activity.
In type 1 diabetic patients, the risk of developing hypoglycemia exists during, immediately after, or several hours after engaging in physical activity, which requires an adjustment in the treatment regimen that patients may be following. Supplemental carbohydrates should be taken if finger prick glucose values are less than 100 mg / dL before starting physical activity.
The key precautions for diabetes exercise programs are as follows:
- Evaluation of the patient before embarking on an exercise program, with a complete physical examination and careful medical tests, with documentation of the degree of retinopathy, nephropathy, and neuropathy (both peripheral and autonomic).
- Resting starting ECG to check for any ST and T segment abnormalities; further stress radionuclide testing may be legitimate.
- Doppler ultrasound and ankle-brachial index if there is evidence of peripheral arterial disease.
- If a patient with sensitive feet were to undertake exercise, ulcerations and fractures may result; exercise with weights should be limited; swimming is the ideal exercise in this case.
- A 5-10 minute warm-up and the cool-down session should always be undertaken.
- Use silicone gel or ventilated insoles as well as polyester or mixed (cotton-polyester) socks to prevent sores and maintain circulation.
- Shoes should always be appropriate.
- Examination of the patient’s feet before, as well as after exercise.
- A diabetic bracelet should be worn and steps should be taken to ensure its visibility.
- An average of 17 ounces of fluids should be consumed at least 2 hours prior to starting activity to maintain adequate hydration.
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