Each month we receive many emails about what a diabetic should eat, from children or spouses whose loved one has just been diagnosed or who is not controlling their diabetes well. Over the years the ADA and AMA have changed these guidelines so that I can not recognize my diet today as having very much to do with the one I went on 19 years ago. If you read the abstracts for this month, you know that the ADA has come out with new dietary guidelines designed to improve the treatment and prevention of diabetes and to simplify the lives of those with diabetes. Before I share with you the latest, I should share that experts have known for years many of the facts that underline these guidelines. Visiting Boston as a newly diagnosed diabetic, we had a lovely dinner with the then Medical Director of Joslin who was a friend and my physician from his years in Virginia. At dessert, he suggested that I order vanilla ice cream and then told me why it would not raise my bold glucose level. He told this to a person who was a relatively new type 1 diabetic and who had been quite ill with the disease. Food was still the enemy and I'm not sure I could have swallowed one teaspoon of that lost treat. Today the ADA says that all carbohydrates, be they pasta, potatoes, cake, or cookies are treated the same under their new guidelines. BUT, and here's the big BUT: they recommend that people eat more vegetables and fruits, and that occasional sweets should fit into the total starches in a daily diet and be covered by medication dosages, and that they do not exceed caloric intake guidelines for the day.
Once again, the ADA is trying to change the idea that sugar is the culprit in causing diabetes. Perhaps it will work, but old ideas are difficult to change and the caveats that go along with these new guidelines do not make eating cake a daily occurrence. With that out of the way, we want to share with you the rest of the guidelines for nutrition and diabetes. They are not a short read, so we will share half this month and finish up next month. So read on and you'll understand exactly what and why.
Medical nutritional therapy (MNT) is integral to total diabetes care and management although it one of the most challenging aspects of diabetes care for many reasons which we have talked about on this site. Achieving nutrition-related goals requires a coordinated team effort that will fail without the support and understanding of the person with diabetes. The ADA suggests that a registered dietitian who is knowledgeable and skilled in implementing diabetes MNT be the team member to provide nutrition care and education. How important this statement is can not be underestimated. Last week I was a patient in one of the country's most prestigious hospitals to have surgery. On my chart my history of type 1 diabetes was noted, but the meals that arrived were not appropriate. My first breakfast was cinnamon-raisin French toast with maple syrup, orange juice and a cheese omelet made with whole eggs, toast and butter. Lunch that day was macaroni and cheese with chocolate chip cookies, after a dietitian had come to the room to apologize for my improper breakfast. When I shared this with the doctor, he released me a day early to my hotel room and food I could control. Excellent medical care; difficulty with weekend ancillary care. Back to the facts.
GOALS OF MEDICAL NUTRITION THERAPY
The overall goal of MNT is to assist people with diabetes in making changes in nutrition and exercise habits leading to improved metabolic control. Listed here are the other goals:
Maintenance of as near-normal blood glucose levels as possible by balancing food intake with insulin or oral medication along with physical activity.
Provisions of adequate caloric intake for maintaining reasonable weight, normal growth rates in children and adolescents, increased needs during pregnancy and lactation, or recovery from illness. Reasonable weight for a person with diabetes may not be defined as the traditionally defined desirable or ideal body weight.
Prevention and treatment of the acute complications of insulin-treated diabetes such as hypoglycemia, short-term illness, and exercise-related problems, and the long term complications that we have spoken of in other articles in What's Hot.
Improvement of overall health through optimal nutrition. This is done with an understanding of the Diabetes Food Guide Pyramid, which is specific for those with the disease.
NUTRITION THERAPY AND TYPE 1 DIABETES
Nutritionists are asked to make up a MNT based on the patients' usual food intake and to make sure it will fit in with these patterns and exercise program. It is recognized that those on insulin eat at times consistent with the time-action of the type of insulin they use. Also, diabetics need to monitor blood glucose levels and know how to adjust insulin doses. Intensified therapy and multiple injections as well as rapid-acting insulin allow for more flexibility in the timing of meals as well as the amount of food eaten. It is important that people taking insulin know how to make these adjustments.
NUTRITION THERAPY AND TYPE 2 DIABETES
Here the primary goals are to achieve and maintain glucose, lipid, and blood pressure goals. Hypocaloric diets and weight loss usually improve short-term glycemic levels and have the potential to improve long-term metabolic control. In the past, weight loss has failed in many type 2 diabetics, and currently it is felt that teaching how to keep tight control of blood glucose levels is most profitable. For this reason only moderate caloric restriction (250-500 calories less than the usual food intake) is suggested along with a nutritionally adequate meal plan with a reduction in fat, especially saturated fat, accompanied with an increase in physical activity. Lowering caloric intake is associated with increased insulin sensitivity. A small weight loss of 10-20 pounds has been associated with reduction in hyperglycemia, dislipedemia and hypertension.
Spacing meals and foods, especially carbohydrates, throughout the day is another strategy that dietitians can help with. Many type 2 diabetics who have limited success with weight loss programs will need education about other strategies, such as medications or surgery.
PROTEIN
There is little research data to establish guidelines specific for those with diabetes so at the present time it is suggested that 10-20% of caloric intake come from protein sources. Dietary protein can be derived from both animal and vegetables sources. With the onset of overt nephropathy, lower intakes of protein should be considered, however the recent Modified Diet in Renal Disease Study in which only 3% of persons had type 2 diabetes and none had type 1 diabetes, failed to show a clear benefit of protein restriction. It is the consensus to prescribe protein intake of 10% of daily caloric intake for those with overt nephropathy. Muscle weakness from nutritional deficiency may occur and needs to be addressed, so it is imperative that an MNT for someone with renal disease should be followed closely by a dietitian.
TOTAL FAT
With dietary protein making up 10-20% of caloric intake, then 80-90% of our calories remain. Less than 10% of those should come from saturated fats leaving the rest to come from carbohydrates and polyunsaturated fats. The amounts of these can vary and be individualized based on a nutritional assessment as well as treatment goals. Recommended percentages of calories from fat will rely on lipid problems and treatment goals for glucose, lipids and weight. People who are at a healthy weight and have normal lipid levels are encouraged to follow the recommendations of the National Cholesterol Education Program (NCEP), which suggests that all people over 2 years of age limit fat intake to <30% of total calories with saturated fat intake < 10%. If LDL is of concern, levels of saturated fat should be lowered to 7% of total calories and dietary cholesterol to < 200 mg/day. Polyunsaturated fats and omega-3 series are provided naturally in fish and other seafood, and intake of these foods need not be curtailed in people with diabetes.
If obesity and weight loss are primary concerns, reduction in dietary fat should be considered. Research in replacing foods with those made with fat replacers is ongoing. If triglycerides and very-low-density lipoprotein cholesterol are the primary concerns, one approach that can be tried is moderate increase in monounsaturated fat intake with < 10% of calories from saturated fats, and moderate carbohydrate intake. In obese individuals care needs to be taken to ensure that increased fat does not aggravate obesity, In addition, people with triglyceride levels greater than or equal to 1,000 mg/dl require reduction of all dietary fat in addition to medication to reduce the risk of pancreatitis. It is very important that patients have glycemic and lipid status monitored to assess the effectiveness of nutrition recommendation.
SATURATED FAT AND CHOLESTEROL
A reduction in saturated fat and cholesterol consumption is an important goal to reduce the risk of CVD. (Cardiovascular disease) @? Should be defined; not common knowledge. Diabetes is a strong independent risk factor for CVD, over and above the adverse effects of an elevated serum cholesterol. therefore < 10% of the daily calories should be from saturated fats, and dietary cholesterol should be limited to less than or equal to 300 mg daily. However, even these recommendations must be incorporated with consideration of an individual's cultural and ethnic background.
Next month we will share facts about carbohydrates and sweeteners, fiber, sodium, alcohol, micronutrients, and pregnancy, and then we will summarize all of the facts that we have presented to you. Keep reading and learning.
BSP
