Nutrition in

Diabetes
mellitus
Dr Alshaymaa Darwish
 What is Diabetes?

Diabetes is a metabolic disorder characterized by chronic hyperglycaemia with

disturbances of carbohydrate, fat, and protein metabolism resulting from defects in insulin
secretion, insulin action, or both.

Hypoglycemic
 How to Diagnosis DM?

NB: Individuals with no history of diabetes may develop acute hyperglycemia under conditions of
severe stress (eg, critically ill individuals hospitalized due to infection, sepsis, trauma, or cardiovascular
event).
DM classification and etiology:
DM complications:

Control Blood
glucose + fats + BP
Can decrease the
risk of disease and
complications
development
 Medical Nutrition Therapy (mnt)

Clinical trials and outcome studies support MNT as effective in improving

metabolic outcomes, such as blood glucose, A1C, lipids, blood pressure,
weight, and/or quality of life in persons with diabetes.
The evidence suggests that MNT is most effective at initial diagnosis, but is
effective at any time during the disease process.
 - In critical illness receive insulin
throughout each 24-hour period without
cessation
- -Individuals with ketoacidosis require
aggressive volume repletion

Type I
 Hyperglycemic hyperosmolar state can result
when glucose levels rise above 600 mg/dL with
severe dehydration and hyperosmolality without
the development of pronounced ketoacidosis

Type II
 Prevention of Diabetes (treatment
prediabetes condition)
-A healthy eating pattern and regular physical activity are important goals of medical nutrition therapy
- Prediabetes, which includes impaired glucose tolerance (IGT) and impaired fasting glucose (IFG) (ADA, 2014).
These conditions also place individuals at higher risk for stress hyperglycemia and glucocorticoid-induced
hyperglycemia during hospitalization.
- Metabolic syndrome, is defined by a cluster of risk factors mechanistically related to insulin resistance, including
abdominal obesity, dyslipidemia, elevated glucose level, elevated blood pressure, and systemic inflammation
(cardiometabolic).
- Prediabetes and metabolic syndrome are conditions that identify individuals at high future risk for the development
of type 2 diabetes and cardiovascular disease events
The treatment for prediabetes and metabolic syndrome is lifestyle modifications, including diet and regular -
exercise (30 minutes/day) with a goal to achieve and sustain Modest amounts of 5% to 10% weight loss to prevent
or delay the diagnosis of diabetes and reduce cardiovascular risk.
aggressive lifestyle interventions and potentially oral medications to decrease blood glucose concentrations for -
individuals with metabolic syndrome & prediabetes
 Prevention of Diabetes complication

 Decrease Food raises blood glucose (

 Exercise and medication lowers it
 Balance these three to keep blood glucose level close to normal.
Glycemic
control

In
addition
to
Control
 2018 Diabetes Canada CPG – Chapter 11. Nutrition

Macronutrient Distribution
(% Total Energy)
ADA systematic review of macronutrients concluded that there is not one effective mix that applies broadly, and that
the mix of carbohydrate, protein, and fat should be 1adjusted to meet the metabolic goals and individual
preferences of each individual.

Carbohydrates Protein Fat

% of total energy 45-60% 15-20% 20-35%
(or 1-1.5g /kg BW)
Calories per gram 4 4 9

Grams for 2000 calorie/day 225-300 75-100 44-78

BW = body weight
 Total calories (T2D)

- Several organizations promote permissive hypocaloric feeding for patients with a body -
mass index (BMI) equal to or greater than 30.
- In this context, hypocaloric is defined as 65% to 70% of target energy requirements, -
- 11 to 14 kcal per kg actual body weight if BMI is between 30 and 50, -
- or 22 to 25 kcal per kg ideal body weight (IBW) if BMI is greater than 50. -
-While insulin sensitivity may be improved with some degree -
of weight loss or reduction in caloric intake by 500 -750
kcal
 Carbohydrates

 In diabetes, carbohydrate management is also a key strategy for glycaemic control.

 There are some factors affecting the blood glucose level include; amount of carbohydrate, type of sugar or starch,
cooking and food processing, food form other foods in the meal that slow digestion (fats)

 Both quality and quantitiy of CHO affect BGL but The most important thing to consider in how foods affect your
blood glucose is the amount of carbohydrate you eat at one time (Total carbohydrate eaten determines how much
sugar reaches your blood) is the main predictor of postprandial glycaemic response .

 The type or source of carbohydrate is much less important.

 Therefore, it’s always best to check your blood glucose frequently.

 Monitoring carbohydrate intake by carbohydrate counting, exchanges, or estimation, and adjusting medical
therapy accordingly, is the key strategy in maintaining optimal glucose control. The minimum carbohydrate
recommendation is 130 g/d
Glycemic control effect
Health eating pattern
 Type 1 DM

➢ Adults, children, and young people with type 1 diabetes are advised to adopt carbohydrate
counting and insulin dose adjustment to manage postprandial glucose excursions, and it is
recommended that this is delivered as part of structured education.

- Flexible insulin regimens using basal (background) insulin and bolus (mealtime) insulin or insulin
pumps give the patient freedom in timing and composition of meals and are the preferred
mode of therapy to maximize blood glucose control and minimize complications (insulin-to-
carbohydrate ratio).

- For persons receiving fixed insulin regimens and not adjusting mealtime insulin doses, consistency
of day-to-day carbohydrate amounts at meals is important.
The 1500 rule estimates the
sensitivity factor or the point
drop in glucose (mg/dL) for
every 1 unit of regular insulin.
The 1800 rule estimates the
sensitivity factor or the point
drop in glucose (mg/dL) for
every 1 unit of rapid-acting
insulin (lispro, aspart, or
glulisine)
 Type 1 DM

-To calculate the sensitivity factor for regular insulin, divide 1500 by the total daily insulin dose. For
example, if the total daily insulin requirement is 60 units, the sensitivity factor is 25 (1500/60 = 25),
- predicting that the blood glucose level will decrease by 25 mg/dL for each unit of regular insulin
given.
- - If the premeal glucose is 195 mg/dL and the target is 120 mg/dL, the glucose needs to decrease
by 75 mg/dL (195 – 120 = 75) to reach the target level. Therefore, 3 units of regular insulin (75/25 =
3) are needed to reduce the glucose level by the 75 mg/dL. The 3 units of regular insulin should be
added to the scheduled insulin dose for that meal to bring the glucose into an acceptable range
leading up to the next meal
- If the glucose decreased 40 mg/dL (eg, from 180 to 140 mg/dL) following an injection of 5 units, the
sensitivity factor is 8 (40/5 = 8). Since insulin lispro, a rapid-acting insulin, was used, the total daily dose
may then be estimated using the rule of 1800: divide 1800 by the sensitivity factor. The patient will
need a total daily insulin dose of 225 units (1800/8 = 225 units).
 Type 2 DM
- Type 2 Diabetes Previously, nutrition advice focused on losing weight and avoiding sugars. Today, the
focus of MNT for type 2 diabetes is to implement lifestyle strategies (reduce energy intake and
increase energy expenditure through physical activity ) that will assist in improving glycemia,
dyslipidemia, and blood pressure.
- Effective nutrition interventions include reduced energy/fat intake, individualized MNT, portion control,
healthy food choices, and carbohydrate counting. CHO monitoring and management is
recommended.
- In terms of the quality of carbohydrate, people with diabetes are advised to adopt the healthy eating
patterns include:
- Eating unrefined, unprocessed, wholegrain carbohydrates (wholegrains, vegetables, fruit, legumes,
and pulses) and
- Restrict refined (white bread, white rice, pasta) and sugary carbohydrates.
- Recent recommendations for free sugars (those added during processing, preparation and cooking)
for the general population have advised that they should be limited to <5% total energy intake, and
this applies equally to people with diabetes.
Fiber recommendations for people with diabetes are the same as for the general population: 25 to 30
g/d (whole grains, vegetables, fruits , beans, peas
 2018 Diabetes Canada CPG – Chapter 11. Nutrition
Adults with diabetes should select carbohydrate food sources with a low GI to help optimize glycemic
control

www.guidelines.diabetes.ca
 Fats

- A long-term high fat and high saturated fat diet are associated with an increase in insulin
resistance.
- Limiting intake of saturated fatty acids to less than 7 percent of total energy, Saturated fat intake
should not exceed 10% of total energy intake and
- should be replaced with monounsaturated fats (olive & canola )when the latter are available;
Foods rich in ω-3 fatty acids (ie, fatty fish, nuts, and seeds) are encouraged
- The ADA also recommends two or more servings of fish per week (with the exception of
commercially fried fish filets).
- consuming minimal trans fatty acids or avoided
- Plant sterol and stanols esters have also been shown to lower total and LDL-C in persons with type
2 diabetes and can be substituted for other fats in the diet, such as margarine or cream cheese.
- Emphasis on the type of fat rather than the amount of fat is recommended.
- Recommendations and dietary guidelines no longer include restrictions on dietary cholesterol
 Protein

- Generally, the normal protein recommendation used for healthy patients with diabetes is 0.8 to
1.0 g/kg/d or 15% to 20% of daily energy intake
- A patient’s protein requirements may increase to 2 g/kg/d during stress or illness.
- For critically ill obese patients, protein needs should be based on IBW, particularly if the patient is
receiving hypocaloric nutrition.
- If the patient’s BMI is 30 to 40, the daily protein recommendation is 2 g per kg IBW;
- if the BMI is equal to or greater than 40, the daily protein recommendation is up to 2.5 g per kg
IBW
- In patients with diabetic nephropathy (albuminuria and decreased glomerular filtration rate),
protein intake of 0.8 g/kg/d is recommended.
- Providing protein below this level has not proven beneficial in altering glomerular filtration rate,
cardiovascular risk, or glycemia.
- In patients with type 2 diabetes, protein may increase insulin responses without affecting blood
glucose; thus, carbohydrate-containing foods that are also high in protein should be avoided
when correcting hypoglycemia.
 electrolyte

- Sodium For both normotensive and hypertensive individuals, a reduction in sodium intake
lowers blood pressure. The
- recommendation for the general public to reduce sodium to <2300 mg/day is also
appropriate for persons with diabetes.
- For persons with both diabetes and hypertension, further reduction in sodium intake
should be individualized.
- Hyperosmolarity from hyperglycemia shifts fluid from the intracellular to extracellular
compartments, resulting in a dilutional decrease in sodium levels. Serum sodium
concentrations decrease 1.6 mEq/L for every 100 mg/dL increase in serum glucose.1
Corrected Serum Sodium = Measured Serum Sodium + [0.016 × (Serum Glucose – 100)].
- Monitoring K and P

- There is also insufficient evidence to support the use of chromium, magnesium, and
vitamin D to improve glycemic control in persons with diabetes.
14 g fiber per 1000 kcal consumed or 25
to 30 g/d.68
 2018 Diabetes Canada CPG – Chapter 11. Nutrition

Choose “healthy” dietary patterns

Mediterranean diet Vegetarian diet

https://oldwayspt.org/traditional-diets/mediterranean-diet https://oldwayspt.org/traditional-diets/vegetarian-
vegan-diet
The Plate Method
 Which Plate is Better??

A 10 inch dinner plate-a typical A 8 inch dinner plate-

dinner plate this is the recommended
plate to use
. Keeping an eye on portion sizes to manage body weight.
 Physical activity

- Exercise helps improve insulin sensitivity, reduce cardiovascular risk factors, control weight, and
improve well-being. People with diabetes can exercise safely.
- The exercise plan will vary depending on age, general health, and level of physical fitness.
- A minimum of 150 min/week of moderate intensity aerobic physical activity (50 to 70 percent of
heart rate) is advised.
- In the absence of contraindications, resistance training three times per week is encouraged.
- Persons taking insulin or insulin secretagogues should monitor their blood glucose and take
appropriate precautions to avoid hypoglycemia; carbohydrate should be eaten if pre-exercise
glucose levels are less than 100 mg/dL (5.6 mmol/L).
 Stage-Targeted Strategies for Type 2 diabetes
Prediabetes Early type 2 diabetes Not on insulin On basal insulin only
• Weight loss or • Weight loss or • Weight loss or • Portion control
maintenance* maintenance* maintenance* • Weight loss or maintenance*
• Portion control • Portion control • Portion control • CHO consistency
• Guidance to include • Low GI CHO • CHO distribution • Low GI CHO
low GI CHO and • High fibre • Low GI CHO • High fibre
reduce refined CHO • CHO distribution • High fibre • Dietary pattern of choice **
• Physical activity • Dietary pattern of choice • Dietary pattern of • Physical activity
** choice **
• Physical activity • Physical activity
On basal-bolus therapy
• Portion control
• Weight loss or maintenance*
• CHO consistency initially then learn
CHO counting
• Low GI CHO
• High fibre
• Dietary pattern of choice **
• Physical activity

*as appropriate
**dietary patterns include Mediterranean, vegetarian, DASH, Portfolio and Nordic dietary patterns, as well
as diets emphasizing specific foods (i.e. dietary pulses, fruits and vegetables, nuts, whole grains and dairy
products), which have evidence of benefit for people with diabetes
Ways to eat well with diabetes9
1. Ea ting regular meals including breakfast.
2. Keeping an eye on portion sizes to manage body weight.
3. Including some carbohydrate. Healthier sources include wholegrains, fruit,
vegetables, legumes, and some dairy foods, e.g. milk, yogurt.
4. R educing the amount of saturated or animal fat found in butter, red and
processed meat products, palm oil, coconut oil, ghee, cakes, and pastries.
5. Including at least five portions of fruit and vegetables daily.
6. R educing salt by adding less in cooking and at the table and eating fewer
processed foods. Approximately 75% of salt eaten is found in
processed foods.
7. Substituting fish for meat and aiming to eat two portions of oily fish
each week.
8. Using more legumes such as beans, lentils and pulses.
9. R educing sugar intake by keeping sugary foods and drinks to an
occasional treat.
 Web site
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