7

Nutrition
and diabetes

Li Jibin, Ph.D
Department of Nutrition and Food Hygiene
School of public health and management, CQMU
Diabetes- What is it?

• Body is not producing or has lost sensitivity to

insulin.
• Insulin is a hormone that is needed to convert blood
glucose into energy or glycogen.
• Insulin is produced in the body by the pancreas.
Types of Diabetes

There are several types of diabetes:

• Type 1 DM: body does not produce any insulin.
• Type 2 DM: body is not making enough or is losing
sensitivity to insulin made.
• Secondary: a consequence from another disease.
For example, pancreatitis or cystic fibrosis.
• Gestational Diabetes: diabetes during pregnancy.
• Impaired Glucose Tolerance: prediabetes, an
intermediate between normal and diabetes.
Etiologic Classifications of Diabetes Mellitus

Type 1 Diabetes Mellitus

• Immune mediated
• Idiopathic (arising from an unknown cause)
Type 2 Diabetes Mellitus

Impaired glucose regulation (IGR)

• Impaired glucose tolerance (IGT)
• Impaired fasting glucose (IFG)
Specific Types of Diabetes Due to Other Causes
• Drug or chemical induced
• Cystic fibrosis or other diseases of the pancreas
Gestational Diabetes Mellitus (GDM)
Quick Review: Anatomy of the Pancreas

• A gland that lies behind the stomach;

• Clusters of cells inside the pancreas known as the
islets of Langerhans produces three hormones;
• The islets contain 3 types of cells: Alpha, beta, and
delta cells.
Pancreas (contd.)

• Alpha cells ： produce glucagon;

• Beta cells ： produce insulin;
• Delta cells ： produce somatostatin;
• These cells have special sensors that monitor
levels of blood glucose and stimulate the release
of the correct hormone.
Anatomy of the Pancreas
Insulin and the other hormones

• Glucagon: Hormone that increases the amount of

glucose in the blood when it is needed.
• Somatostatin: Hormone that can suppress both
glucagon and insulin when needed.
• Insulin: Hormone that lowers blood glucose.
How Does Insulin Work?

• A person normally secretes insulin in response to

an elevated blood glucose level.
• It does this by accelerating blood glucose
movement out of the blood and into the cells.
• Cells will not allow blood glucose in without insulin.
- this can cause a problem.
How Does Insulin Work?

Insulin stimulates body cells, such as fat cells and muscle cells, to
take up the glucose to be used for energy or storage.
The role of insulin in cellular uptake of glucose
Why isn’t the body making insulin?

• In people with type 1 diabetes, the immune system

has made a big mistake! It attacks the beta cells
and destroys them!
• In people with type 2 diabetes, the pancreas is still
making insulin, just not enough to keep up, or their
bodies have become insulin resistant!
Type 1 diabetes

• Usually diagnosed in children and young adults

(used to be called juvenile-onset diabetes).
• Must take daily insulin shots to stay alive (used to
be called insulin-dependent diabetes).
• Type 1 diabetes accounts for 5%~10% of the
population with diabetes.
Type 2 diabetes

• The most common form of the disease.

• Approximately 50% of men and 70% of women are
obese at the time of diagnosis.
• T2DM is still on the rise in many countries due to
increase of older population, greater occurrence of
obesity and sedentary lifestyles.
Gestational Diabetes

• Pregnant women have a higher insulin level.

• If woman has hyperglycemia, her blood glucose
crosses the placenta but her insulin does not.
• This can cause a high birth weight for baby.

• Normal birth weight

ranges from 2.5~4.0kg,
over 4.0kg was called
macrosomia. The baby
here in the picture has a
birth weight as high as
5.6kg.
What are the Symptoms?

• Polyphasia: excessive eating

• Polyurea: excessive urination
• Polydypsia: excessive fluid intake
• Retinopathy: blurred vision, retinal detachment,
blindness
• Nephropathy: microalbuminuria, end-stage renal
disease
• Neuropathy: small nerves damage, irritability,
prickly sensation, lose of sensation, infection and
poor wound healing, amputation
• CVDs: hypertension, dyslipidemia, arthrosclerosis
Diagnosis

Criteria for diagnosis of diabetes:

• Symptoms of diabetes plus casual plasma glucose
concentration 11.1 mmol/L
OR
• Fasting plasma glucose 7.0 mmol/L
OR
• 2-hour post-prandial glucose 11.1mmol/L during an
oral glucose tolerance test (OGTT)

Note: 1mg/dl=0.056mmol/L
Diagnosis (contd.)

Criteria for IGR (impaired glucose regulation)

• IFG: Impaired fasting glucose, fasting plasma
glucose is >6.1mmol/L and <7.0mmol/L.
• IGT: Impaired glucose tolerance, 2-hour post-
prandial glucose >7.8mmol/L and <11.1mmol/L
during an oral glucose tolerance test.

Note: 1mg/dl=0.056mmol/L
 Criteria for IGR (IFG or IGT) and DM

DM
7.0
Fasting glucose mmol/L

Impaired fasting glucose, IFG IFG+IGT

6.1

intolerance, IGT
Impaired glucose
Normal glucose

7.8 11.1
2 hr Post-prandial glucose mmol/L

Note: 1mg/dl=0.056mmol/L
Who’s at risk?

• Age: Screening for diabetes should be considered

for all patients at age 45. If the results are normal it
should be repeated every 3 years.
Prevalence of DM by Race, Sex, and Age Group U.S., 2007
 Who’s at risk? (contd.)
• Other risk factors: Screening should be considered
at a younger age if patient meets following risk
factors:
– Overweight and obesity.
– Genetics: First degree relative with diabetes or high ethic
group.
– GDM: diagnosed with gestational diabetes or delivered a
baby with marosomia.
– Hypertension
– Dyslipidemia: HDL level<35mg/dL or TG >250mg/dL.
– IGR: Impaired glucose tolerance or impaired fasting
glucose on a previous test.
Management of DM
The five keys are as follows:
1. Health education
2. Nutritional therapy
3. Exercises prescription
4. Medication and insulin treatment
5. Monitoring blood glucose and complications
Treatment Goals for Type 2 DM

• Achieve normal or near-normal blood glucose

levels.
• Provide adequate calories for reasonable body
weight.
• Prevent, delay or treat nutrition related
complications.
• Improve health through optimal nutrition.
Exercise and Type 2 DM

Especially beneficial in type 2 DM

• Promotes weight loss.
• Increases insulin sensitivity.
• Must also be aware of medication and intake to
prevent hypoglycemia.
Nutritional therapy of Type 2 DM

Diet plays a major role

• Carbohydrates are the component of food that
causes an increase in blood sugar.
• Diabetics are encouraged to keep track of the
amount of carbohydrate they eat.
Methods of Carbohydrate Control

• Two common methods of controlling diabetes.

– Exchange list system
– Carbohydrate counting: Very basic, allows a little
more freedom and variety.
Carbohydrate counting

One of the four meal planning approaches.

• Basic concept
– The carbohydrate found in foods is the major
macronutrient influencing post-prandial glucose
variations.
– It influences pre-meal insulin requirements. The
total amount of daily carbohydrate intake, not its
source, is the focus of this meal planning
approach.
– Food carbohydrate sources are starches, fruits,
milk/yogurt, and sweets.
Carbohydrate counting (contd.)

• Method: Carbohydrates can be counted in one

of the following two ways:
– The amount of food containing 15 g carbohydrate
counts as one carbohydrate choice.
– Total grams of carbohydrate in a meal or snack can
be counted by use of food label information or other
sources of nutrient analysis information.
Example
Case: Mr. A, a 24-year-old male, has T1DM. Using
the recommended standards for percentage of kcal
from carbohydrate and his diet history, you determine
that he should consume approximately 55% of his
total energy (assuming his energy intake is 2200kcal)
from carbohydrate.
Question: How much carbohydrate choices Mr. A
can consume per day?
Example (contd.)
• Step 1: Take energy intake and multiply by 55%.
2200×0.55=1210 kcal from CHO
• Step 2: 1210 kcal/4=302 grams of CHO
• Step 3: Determine the number of CHO choices for
the 24 hour period—302 g/15 g per choice=20.
Mr. A can consume 20 CHO choices in the 24-hour
period. This amount will be adjusted according to
his weight, hunger, and physical activity levels.
• Step 4: Divide the CHO choices between meals
and snacks so that Mr. A will know the amount of
rapid-acting insulin he should use at each meal.
Exchange Lists

A widely used method for planning food intake.

• Basic concept
– The exchange system sorts foods into groups by
their proportions of carbohydrate, fat, and
protein. These groups may be organized into
several exchange lists of foods.
– Each food portion on a particular list can be
exchanged with any other food portion on the
same list.
 Exchange groups

Food
Food Exchange
Exchange Energy
Energy CHO
CHO Protein
Protein Fat
Fat
（ gg ）
）
（ gg ） （ gg ）
serving （
groups
groups serving （（ kca
kca （ ） （ ）
ll ）
）
Cereals 1 90 19 2 0.5

vegetable 1 80 15 5 -

Fruits 1 90 21 1 -

Lean 1 80 - 9 5
meat
Dairy 1 80 6 4 5

Fats & 1 80 - - 9
oils
 Cereals group list

Food Food (grams) Food (grams) Food (grams)

group
Cereals Rice, flour 25g Rice noodle 25g Chinese yam 125g
Per Noodle 25g Mung bean 25g Lotus root starch 25g
serving Corn 25g Soda cracker 25g Water chestnut 150g
Bread 37.5g Bean jelly 400g White fungus 25g
Wet noodle 30g Potato 125g
Arrowhead 75g
 Vegetables group list

Food group Food (grams) Food (grams)

Vegetables high in sugar Squash 350g Fresh peas 100g

(CHO>4%) Sweet pepper 350g Green bean 250g
Per serving Luffa 300g Cowpea 250g
Lentils 250g
Vegetables low in sugar Bok choy, cabbage, spinach, rape, leek,
(CHO<3%) celery, lettuce, tomato, wax gourd,
Per serving cucumber, bitter gourd, eggplant, bean
sprout, cauliflower, mushrooms 500g
 Fruits group list

Food Food (grams) Food (grams) Food (grams)

group
fruits Pear 250g Grape 200g Apple 200g
Per Peach 175g Plum 200g Dates 100g
serving Watermelon 750g Leachy 100g Banana 250g
Tangerine 275g Orange 350g
 Meats and beans group list

Food Food (grams) Food (grams) Food (grams)

group
Meats Pork 25g Fish 75g Pork tongue 125g
and Clam 100g Beef 50g Lame 50g
beans Rabbit meat Shrimp 75g Poultry 50g
Per 100g Egg 55g Soy bean 20g
serving Sausage 20g Chops 25g Shredded tofu 50g
Liver 70g Pork floss 20g Tofu 100g
 Dairy products group list

Food Food (ml) Food (ml)

group
Dairy Milk 110ml Yogurt 110ml
Per Condensed milk 60ml Soy milk 500ml
serving Powdered milk 15ml
 Fats and oils group list

Food group Food (grams) Food (grame)

Fats and oils Vegetable oil 9g Sesame paste 15g

Per serving Wall nuts 12.5g Peanuts 15g
Pumpkin seeds 30g
Exchange Lists (Chinese Diabetes Association)

Using exchange list to calculate a meal plan

1. Assess energy intake.
2. Translate energy prescription into exchanges.
3. Determine how to distribute exchange groups
among meals and snacks.
 Estimating patient’s energy intake

Underweight Normal Overweight

Activity level
kcal/kg/d kcal/kg/d kcal/kg/d

Sedentary 25~30 20~25 15

Lightly active 35 30 20~25

Moderately active 40 35 30

Heavily active 45~50 40 35

Note: Energy intake is based on ideal weight.

Ideal weight (kg)=height (cm)-105
 Meal plans at several energy levels using the
exchange lists
Enenrgy
Enenrgy Cereal
Cereal Vege
Vege Meat
Meat Dairy
Dairy Fruits
Fruits Fats
Fats Total
Total
kcal
kcal （ nn ）
（ ） （ nn ）
（ ） （ nn ）
（ ） （ nn ）
（ ） （ nn ）
（ ） （ nn ）
（ ） （ nn ）
（ ）
1000 6 1 2 2 - 1 12

1200 7 1 3 2 - 1.5 14.5

1400 9 1 3 2 - 1.5 16.5

1600 9 1 4 2 1 1.5 18.5

1800 11 1 4 2 1 2 21

2000 13 1 4.5 2 1 2 23.5

2200 15 1 4.5 2 1 2 25.3

2400 17 1 5 2 1 2 28
Example #2
• Case: Mr. B, a 68-year-old retired male, has
T2DM, receiving medications and dietary
treatment. Light physical activity level. Height
1.67M, body weight 75kg.
• Question:
1. Is Mr. B’s body weight normal?
2. How much energy does Mr. B need?
3. How many total exchange servings?
4. Make a meal plan for Mr. B.
Example #2 (contd.)
• Step 1: Mr. B’s ideal body weight is: 167-105=62 kg
The actual body weight is 75 kg. So, his body
weight is above the ideal body weight 20.9%. He is
overweight.
• Step 2: The total energy is: 20kcal/kg×62 kg=1240
kcal. That’s close to 1300 kcal.
• Step 3: According to 1300 kcal level, the total
exchanging servings is 16, of which, 8 for grains, 1
for vegetables, 3 for meats, 2 for dairy, 1.5 for fats.
Example #2 (contd.)
• Step 4: The exchanging servings are distributed
among the three meals according the ratio: 1/5, 2/5
and 2/5.
Breakfast: grains 2 servings, dairy 1 serving, some
vegetable;
Lunch: grains 4 servings, meats 2 servings, some
vegetable and fats (cooking oil);
Diner: grains 2 servings, meats 1 serving, some
vegetable and fats, dairy 1 serving.
 Example #2 (contd.)
• Step 5: Resort to the exchanging lists, selecting the
specific food and the amount.
Meals Servings Menu
Breakfast Grains 2 servings one steamed bum (100g)
Dairy 1 serving a cup of soymilk (200 ml)
Vegetable cucumber salad

Lunch Grains 4 servings a bowl of rice (200g)

Meats 2 servings stir fried parsley and pork (lean
Vegetable pork 50g, parsley)
Cooking oil garlic cauliflower
Diner Grains 2 servings a bowl of rice (100g)
Meats 1 servings Mapo Tofu (tofu 150g)
Vegetable Stir fried lettuce
Cooking oil a cup of milk (100ml)
Dairy 1 serving
Menu for type 2 diabetes (energy level 1300 kcal/d)

Breakfast
• one steamed bum (100g)
• a cup of soymilk (200 ml)
• cucumber salad

Lunch
• a bowl of rice (200g)
• garlic cauliflower
• stir fried parsley and pork (lean pork 50g, parsley)

Diner
• a bowl of rice (100g)
• Mapo Tofu (tofu 150g)
• stir fried lettuce
• a cup of milk (100ml)
Insulin treatment

Insulin
• Sometimes type 2 diabetes patients also need
insulin treatment.
• There are more than 20 types of insulin.
Oral Medications

Four basic types for Type 2 DM

• Sulfonylurea: stimulates the body to make more
insulin.
• Metformin: lowers blood sugar by helping the
insulin work better.
• Thiazolidinediones (TZDs): increase muscle
sensitivity to insulin.
• Alpha-glucosidase inhibitors: slow the process of
carbohydrate digestion.
Diabetes Complications and prevention

• Diabetes complications are the seventh leading

cause of death. They include:
– Blindness- caused by diabetic retinopathy.
– Kidney Disease- diabetic nephropathy
– Heart Disease and Stroke
– Nerve disease
– Impotence
– Amputations

Biology of Microvascular Complications

Diabetes Complications and prevention

• Ketoacidosis
– Develops when the body does not have enough
insulin. The body can’t break down sugar so it
breaks down fat instead. Ketones are what is left
from this process.
• Symptoms that may result in ketoacidosis occur
when:
– Too little insulin has been ejected, or insulin is
not effective.
– Consumed more food and/or exercised less than
expected.
– High blood sugar, high levels of sugar in the
urine, frequent urination, and increased thirst.
Diabetes Complications and prevention

• Hypoglycemia- low blood sugar

– Usually can lower it by exercising, or injecting
more insulin.
– Happens to everyone with diabetes
– Symptoms include shakiness, dizziness,
sweating, hunger, headache, pale skin, sudden
moodiness, clumsy or jerky movements,
difficulty paying attention, and tingling
sensations around mouth.
• How to treat Hypoglycemia: If hypoglycemia goes
untreated, patient could get worse and pass out!
– Stress the importance of a night time snack in
older patients.
– Quickest way to raise blood glucose is with some
form of sugar.
– 3 glucose tablets, 1/2 cup of fruit juice, 5~6 pieces
of candy.
– Wait 15-20 minutes and test blood sugar again. If
still low retreat.
Monitoring

• All diabetics must keep track of blood glucose levels.

- It’s the only way to know if the treatment is effective.
- Gives the diabetic a good indication of what affects their
blood sugar level.
- Must check at least 2 times a day and four times a day for
at least 3 days a week.
Blood glucose monitoring
• (A) Inserting the blood
glucose strip;
• (B) loading the finger pricker.
Blood glucose monitoring
• (C) pricking the finger;
• (D) applying the blood to the
testing strip.
• (E) awaiting result.
Blood glucose monitoring
• Continuous monitoring

Continuous Glucose Sensors

This profile shows very stable blood glucose control with most
values between 5~10 mmol/L.
These profiles show that the patient was frequently hypoglycemic
during the night, while glucose control during the day was poor.
Hemoglobin A1c

Glycated hemoglobin assays (Hemoglobin A1c)

• It’s a good indicator of blood glucose control.
• Performed 2 times a year.
• A hemoglobin of 6% indicates good control and
level >8% indicates action is needed.
 Correlations between A1C Level and Mean
Plasma Glucose Levels

Note: Based on a normal A1C of 6.

Study questions
• How is diabetes diagnosed?
• What are the goals of medical and nutrition therapy for
people with diabetes?
• Describe the meal-planning strategies they can use to
control carbohydrate intakes.
• Meal planning using exchanging list.
Multiple choice
1. Which of the following describes type 2 diabetes?
a. It is usually an autoimmune disease.
b. The pancreas makes little or no insulin.
c. Diabetic ketoacidosis is a common complication.
d. Chronic complications may develop before diagnosed.

2. The chronic complications associated with all types of

diabetes result from:
a. altered kidney function.
b. infections that deplete nutrient reserves.
c. weight gain and hypertension.
d. damage to blood vessels and nerves.
3. Which of the following statements correctly describes
the action of insulin?
a. Insulin controls the entry of glucose into the cell.
b. Insulin increase the conversion of glycogen to
glucose.
c. Insulin decreases the conversion of glucose to fat for
storage as adipose fat tissue.
d. Insulin allows fat to be converted to glucose as
needed to return the blood glucose levels to normal.
4. If 50% of the total energy in a 1500 kcal diabetic diet is
from carbohydrates, how many grams of carbohydrate
will the diet contain? (Round to nearest whole number.)
a. 50
b. 150
c. 190
d. 210