Diet and medical problems Diabetes

Case: A.P. is a 47-year-old woman diagnosed with diabetes five years ago. She recently started on metformin and is tolerating it well. The need to start medication has motivated her to work on losing weight and controlling her disease. She wants to know what she should eat and not eat.

The recommended diet for people with diabetes follows all the same guidelines of a normal healthy diet.14 The diet should contain carbohydrate, protein, and fat in reasonable proportions. Calories should be at a level that promotes a healthy weight, and the diet should be based on the intake of a variety of foods.

The major nutrient that affects blood sugar levels is carbohydrate in the form of sugar and starch, as found in grains, fruits, vegetables, sweets, and milk. The total amount of carbohydrate consumed is more important than the source or type (evidence level A). Sucrose, or table sugar, does not increase blood sugar any more than the same amount of starch, so sucrose can be substituted for other carbohydrates in the diet. There is no evidence to support the avoidance of concentrated sweets as long as total energy and carbohydrate levels are maintained. Non-nutritive sweeteners such as aspartame, saccharin, acesulfame potassium, and sucralose, are safe at normal levels of intake.

Protein, while an insulin stimulant, does not increase blood sugar in the amounts usually eaten. Hyperglycemia can contribute to increased protein turnover. However, since most adults eat much more protein than is required, there is no need for diabetics to increase protein intake beyond usual levels (evidence level B). For those with diabetic nephropathy, reduction of protein intake to 0.8 g per kilogram of body weight may slow the progression of renal disease (evidence level C).

Whereas dietary fat helps to modulate the absorption of glucose, saturated fat and cholesterol should be limited in the diet. Saturated fat in the diet stimulates low-density lipoprotein (LDL) cholesterol production, and people with diabetes are more sensitive than the general population to dietary cholesterol. Less than 10% of calories should come from saturated fats, and dietary cholesterol should be less than 300 mg/day. Some individuals may benefit from lowering intake further (7% saturated fat, 200 mg/day cholesterol) (evidence level A). Intake of trans fatty acids should be minimized (evidence level B).

Both reduced energy consumption and weight loss improve insulin resistance and blood glucose levels. In patients with impaired glucose tolerance, weight loss of 10-15% maybe sufficient to hold off frank diabetes. Weight-reduction diets by themselves are unlikely to result in long-term weight loss. Lifestyle changes that include nutritional, behavioral, and exercise components can reduce weight by 5-7% in the long term. Reduced fat and calories, regular physical activity, and provider contact and support are recommended (evidence level A).

Early studies suggested a positive effect of dietary fiber on blood sugar levels.14 Very large amounts are necessary to confer metabolic benefits, and it is not clear whether these outweigh the side effects of this intake. Individuals with diabetes do not need to consume more fiber than the general population (evidence level B).

Because diabetes maybe a state ofincreased oxidative stress, vitamins maybe of benefit. Placebo-controlled trials of antioxidants have failed to show a benefit and, in some cases, have raised concern about adverse effects. B-complex vitamins have been considered in the treatment of diabetic neuropathy, but benefit has not been established. Deficiencies of certain minerals (potassium, magnesium, zinc, chromium) may worsen carbohydrate intolerance. Benefit from chromium supplementation has been reported, but conclusions are limited by methodological issues in the studies. In all, there is no clear evidence of benefit from vitamin or mineral supplementation for women with diabetes, with the exception of calcium for osteoporosis prevention. Routine use of antioxidant supplements is not advised because of questions regarding long-term safety and efficacy (evidence level B).

Treatment of hypoglycemia is best accomplished with oral glucose or glucose-containing food. The addition of fat retards the absorption of the glucose and should be avoided. Adding protein to the treatment does not affect the glycemic response, nor does it prevent subsequent hypoglycemia. Ten grams of oral glucose will raise blood sugar levels by about 40 mg/dl over 30 minutes, and 20 g will raise blood sugar levels by about 60 mg/dl over 45 minutes.15

To give tailored information about dietary changes, one must first have a complete diet history. This is accomplished most easily by having the patient complete a three-day record, either at home or while waiting for the doctor. Small meals and snacks are preferable to large meals. Low fat (but not no fat) should be the goal. The New American Plate maybe a helpful model. Sometimes, having the patient eat from a smaller plate helps in portion control. Patients should be encouraged to eat more fruits and vegetables but to restrict juice and sweetened drinks to no more than 0.25-0.5 lper day. Monounsatu-rated fats (such as olive or canola oil) should be used to replace saturated fats in cooking.

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