DIET THERAPY FOR DIABETES MELLITUS

Proper dietary management still remains the most important factor in the
treatment of DM. Diet for the diabetic patients should be individualized to meet the
patient’s needs & to be effective. He must be fully aware of the rationale for the dietary
restriction. Like other therapeutic diets, the diabetic diet is a modification & should be
based on an adequate normal diet. It should consist of sufficient calories for the
patient’s activity, maintain DBW & should be adequate in macro & micro nutrients.
Achieving balance between food intake, medication & energy expenditure is an
essential prerequisite for achieving glycemic control. Nutrition advice must be adapted
to cultural, ethnic family traditions & to individual requirement of the patient. The
psychological significance of feeding patterns, appetite & taste must be fully considered.
The making out of the diet prescription should be determined by a physician.
Patient interview usually conducted by the dietician should include a carefully recorded
diet history to determine the patient’s socio-economic conditions, food attitudes & eating
habits, which are factors that may influence the patient’s willingness to accept the diet
planned for him/ her.

Diabetes’ Meal Plan – A guide that that tells a patient how much & what kind of food he
can choose to eat at meals & snack times. A good meal plan should fit in with his
schedule & eating habits. People with diabetes have to take extra care to make sure
that their food is balanced with insulin & oral medications & exercise to help manage
their blood glucose levels. Ways how to help a patient follow his diabetes meal plan
include using the food guide pyramid, exchange lists, plate method & CHO counting.
The simplest is the plate method.

Energy Allowance – determined based on the px’s ht, wt, age, sex & occupation or
activity. Energy level should be adjusted depending upon the px’s individual needs. The
actual weight of the px should be the object of careful analysis & control of total energy
intake to attain DBW should be the primary objective. The diet should be one which will
supply sufficient energy to maintain or attain DBW taking into account the patient’s
activity & lifestyle.
Regardless of the macronutrient mix, the total calorie intake must be appropriate
to the weight management goal. Individualization of the macronutrient composition will
depend on the metabolic status of the patient e.g. lipid profile & renal function and/or
food preferences. Plant based diet (vegan or vegetarian) that are well planned &
nutritionally adequate have also been shown to improve metabolic control.
The following is a convenient guide for calculating the total amount of calories the
patient needs per day for each kg DBW & activity:
 Sedentary Light Moderate Marked Activity
Overweight 20-25 30 35 40
Normal 30 35 40 45
Underweight 35 40 40-50 50-60

Protein Allowance – After the caloric allowance has been determined, the protein
allowance of the patient is then established. Again the DBW of the patient is used as the
basis for calculation. The CHON allowance for the diabetic px is in general, the same as
that of the normal individual. For the adult man & woman, it is computed at 1.1 g/kg
DBW or about 10-20% of total calories. Due to an increase in albumin excretion rate,
intake of CHON above 20% of total kcal ay be a risk factor in developing diabetic
nephropathy. The presence of nephropathy will require a lower CHON intake. Restricted
CHON diets may modify the underlying glomerular injury & while controlling HPN &
hyperglycemia delay the progression of renal failure. A CHON intake of 0.6-0.8 g/kg/day
is recommended.

Carbohydrate Allowance – The estimation is guided by the patient’s blood sugar,

urinalysis data & available insulin. For normal adults, CHO provide 50-70% of TER. In
diabetic patients, the range of CHO intake should be 45-65% of total calories. Foods
containing CHO from whole grains, fruits are maybe incorporated into the patient’s meal
& are not easily detrimental since they are not absorbed any faster than any starches in
the diet.

Fat Allowance – intake should be individualized according to the client’s health goals.
Recommendation is usually 25-30% of total calories, Diabetics are particularly
susceptible to atherosclerosis & its complications; thus consumption of a diet containing
saturated fats should be limited to 1/3 or less of the fat calories & unsaturated fats must
be provide 2/3 of the fat calories. Cholesterol intake should be limited to 300 g/day.

Vitamins & Minerals – requirement is same as those of normal patients. There is no

need for routinely prescribing supplementation when the diet is adequate & the
glycosuria is controlled. However, those with poorly controlled diabetes, patients on
extremely restricted diets, strict vegetarians, the elderly, pregnant or lactating mother,
those taking medications known to alter micronutrient metabolism & patients in critical
care environment may require vitamin & mineral supplementation.

Fiber – High fiber diets especially soluble fibers may offer some improvement in CHO
metabolism, may lower cholesterol, LDL & increase satiety effect of a meal. The
American Diabetes Association recommends that the diabetic diet contain 20-35 g of
dietary fiber per day from a wide variety of food sources rather than from fiber
supplements. It is encouraged that the fiber be derived from foods such as legumes,
tubers & green leafy vegetables, whole grain cereals & fruits with edible skins. Fiber
should be increased gradually along with concomitant increase in CHO & fluid content
of the diet.

Artificial Sweeteners – can be used by people with diabetes & may help control calorie
intake as these sweeteners do not affect blood sugar levels.
 Saccharin – a widely used sweetening agent that may be added to beverages &
food s that do not require cooking. 300 times as sweet as sucrose. ADI: 15mg/kg
BW or 1000 mg/ day for adult, 500 mg/day for children

 Aspartame – 200 times sweeter than sucrose & available as Nutra-sweet &
Equal. ADI: 500 mg/kg/day

 Acesulfame K – non-nutritive sweetener 200x sweeter than sucrose & used for
baking. Example: Sunnet or Sweet One

 Sucralose – non-caloric high intensity sweetener derived from ordinary sugar. It

is 600x sweeter than sucrose. Example: Splenda

 Neotame – Newest non-nutritive sweetener. A derivative of the peptide

composed of 2 amno acids, aspartic acid & phenylalanine. 7,000 to 13,000
sweeter than sucrose. Approved as general sweetener in Australia & New
Zealand.

 Alitame – 2,000x sweeter than sucrose & formed from the amino acids L-
aspartic & D-alanine & a novel amine used for for food & beverages.

 Cyclamates – 30x as sweet as sugar cane & were used to sweeten

softdrinks.Use was stopped after a toxic report on rat.

 Caloric or Nutritive Sweetener – includes sucrose, fructose, sorbitol & other

sugar alcohols.

 Fructose – Most sweet in slightly colder & slightly acidic foods. Often used in
“sugar free” or diabetic commercial products.
  Sorbitol, Mannitol & Xylitol – also added to diabetic foods & drinks for
sweetening purposes because they are absorbed far slower into the blood
stream thus, being recommended by doctors as advantageous among diabetics.

 Stevia – latest sugar substitute that is closest to table sugar but most expensive.
Available as tablets, liquids, powder & extracts. Read labels for equivalence to
table sugar. Example: Truvia & Sweetleaf

Alcohol – has many disadvantages for clients with diabetes. It may cause specific
problem with hypoglycaemia, neuropathy, glycemic control, obesity and/ or
hyperlipeidemia. Alcohol contains 7 kcal/g & its use may be contraindicated in
individuals on a hypocaloric diet.

Guidelines among DM Clients who choose to drink alcohol:

1. Alcohol should be consumed in moderation, not > 2 equivalents of alcohol once
or twice per week
2. Individuals taking hypoglycaemic medications such as insulin or oral agents
should not drink alcohol in a fasted state as hypoglycaemia may ensure.
3. Alcohol should only be ingested with meals to avoid potential hypoglecemic
effect.
4. Alcohol &nits equivalent caloric content should be calculated into the meal plan.
It is best substituted for fat exchanges. 1 equivalent is equal to 90 kcal (2 fat exc)

A. Dietary Guidelines Before & After Surgery

 Patients on oral hypoglycaemic drugs should stop intake a day prior surgery.
 Insulin is used when control of hyperglycemia is needed.
 Sufficient food of high CHO content & sufficient insulin to oxidize the CHO should
be given up to 12 hours before operation.
 Fluids should be given in abundance.
 Give parenteral saline & glucose in emergency operations where coma &
acidosis are more likely to occur.
 Feedings high in CHO either in the form of glucose or saline should be given
within 3 hrs after operation
 Start liquid diet as soon as possible
 Full liquid if can be given should meet the CHON, CHO & fat allowance of the
patient

B. Dietary Guidelines in Gestetional Diabetes

 3 meals & in-between snacks should be stressed.
  Fruit exchange is not given for breakfast but planned later as mid-morning snack
because the FBS of pregnant woman is usually high in the AM.
 For obese pregnant woman with BMI of >30, caloric restriction of about 25
kcal/kg BW/ day is recommended. Average: 1,700 kcal/ day
 Choose starchy, whole grain & foods that are high in fiber to prevent
constipation.
 Caloric distribution: CHO (40-45%), CHON (30-35%), fats (30-35%)
 Vitamins & minerals as prescribed by the doctor

C. Dietary Guidelines in Children

 Dietary modification is similar to that of an adult. Meal plan is based on complete
nutritional assessment.
 Energy to maintain desirable rate of growth:
- 1 to 9 years old (80 kcal/ kg DBW per day)
- 10 to 18 years old (55 kcal/ kg DBW per day)
 Protein recommendation: average of 1.9 g/kg DBW for children 1 to 9 yrs old
1.3 g/ kg DBW for children 10 to 18 years old
 Carbohydrates& Fats – 50% of total calorie is CHO, remaining is fat (35%)
 Vitamins & Minerals – additional calcium requirements are easily met when 3-4
cups of milk are included daily. The diabetic diet should be generously supplied
with green leafy & yellow vegetables as well as appropriate cooking oil & butter
or margarine which would supply the needed vitamins as well as fat.