Diabetes Diet Guidelines and Healthy Eating Plan - HUMAINOLOGY

The Diabetes Diet Therapy & Eating Well

                                       

Diet for Diabetes patients

Diabetes mellitus is characterized by an inability to metabolize carbohydrate due to a deficiency of insulin or a deficiency of receptor sites. The metabolism of protein and fat is also affected. Glucose is the form of carbohydrate that is carried in the blood; all carbohydrate breaks down to glucose. Without glucose, the cells have no energy source and have to use muscle protein and tissue fat as an alternate. Without insulin, glucose cannot go from the blood into the cells. This glucose accumulates in the blood, producing hyperglycemia. The sources of blood glucose are: 1. Carbohydrate (CHO): 100% of digestible CHO converted to glucose. 2. Protein: 58% converted to glucose. 3. Fat: 10% converted to glucose. 4. Glycogen (the liver’s emergency supply of carbohydrate): converted to glucose when other sources are used up. Muscle tissue also contains glycogen that may be used in emergencies. Blood glucose is controlled by two hormones from the beta cells of the pancreas: insulin, which lowers blood sugar, and glucagon, which raises it. A third hormone, somatostatin, regulates the secretions of these two hormones. 

TREATMENT AND DIET THERAPY

Although the cornerstone of treatment for diabetes mellitus is diet therapy, there are some differences in the way that the therapy is applied, depending upon the type of diabetes present. The general classification of diabetes is based upon two major types: type I, insulin-dependent diabetes mellitus (IDDM); and type II, non-insulin-dependent diabetes mellitus (NIDDM). Eighty-five to ninety percent of the diabetic population is non-insulin dependent; the other 10 to 15 percent is insulin-dependent. The following discussion illustrates some of the similarities and differences between these types of diabetes.

Type I—IDDM 

This is the most severe form of diabetes, occurring most often in childhood or young adulthood. It may, or may not, be an inherited trait. Recent research indicates that the islet cells of the pancreas may have been damaged, either by a disease (such as rubella) or by certain chemicals that were toxic, which led to the onset of the disease. The classic symptoms of IDDM are polydipsia, polyphagia, and polyuria, accompanied by rapid weight loss and often ketoacidosis. IDDM has a rapid onset, is very unstable, and causes metabolic imbalances that are difficult to control. For these reasons the diet is very carefully planned and coordinated with the insulin and exercise regime. Failure to time and regulate the meals with these factors will result in great fluctuations in blood glucose, ranging from acute hypoglycemia to extreme hyperglycemia. Diet therapy is discussed at length later in this chapter. 

Type II—NIDDM 

NIDDM has a much stronger genetic link than does IDDM. The majority of these clients are older adults because the onset is slow, and they are usually obese. Some endogenous insulin is still produced, making it unnecessary for them to take insulin, except in unusual situations (such as surgery or other stressors). Obesity, physical inactivity, and hypertension are strong risk factors for the onset of NIDDM. The symptoms are similar to those of IDDM, except there is no weight loss and very rarely ketoacidosis. NIDDM is a milder form of diabetes and is most often controlled with weight loss and an exercise program. Occasionally an oral hypoglycemic drug will be necessary. Persons with NIDDM have a high incidence of atherosclerosis, making it advisable to counsel them on the need for reduced fat intake as well as reduced calories. As we have advanced in our knowledge of treatments for diabetes, diabetic persons are living longer. They have increased risks of developing major complications such as kidney disease, vascular disease, nerve impairment, and diseases of the retina of the eye. In fact, as much as 20% of the diabetic population becomes blind. Fluctuations of blood glucose from uncontrolled diabetes are thought to be one important factor in the onset of these conditions, making it even more imperative to manage and monitor the diet carefully

Diabetes Diet Guidelines and Healthy Eating Plan - HUMAINOLOGY

BASIC NUTRITION REQUIREMENTS 

Basic nutrition requirements will be determined by several factors. Some of the guidelines used are physical assessment, health and diet histories, and laboratory reports. These factors, combined with the psychological aspects of the client, will help the physician or healthcare specialist determine the diet prescription.

Nutrient Balance

In the most widely used diabetic diet plans, daily carbohydrate intake provides 50%–55% of the daily caloric requirement. Protein of high biological value is emphasized for diabetic diets, especially for children and adolescents. Protein provides 15%–20% of the daily caloric intake. Emphasis is placed on using polyunsaturated fats and limiting cholesterol in the remaining 30% of calories permitted for dietary fat. An example will serve to illustrate the concept of nutrient balance: Mr. X is placed on a 1500 calorie per day diabetic diet. The nutrient balance is 50% carbohydrate, 20% protein, and 30% fat. What is the number of grams of each nutrient used in the daily diet plan? 1. Carbohydrate 1500 calories .50 750 calories 750 calories/(4 calories/g) 187 g carbohydrate, rounded to 190 g 2. Protein 1500 calories .20 300 calories 300 calories/(4 calories/g) 75 g protein 3. Fat 1500 calories .30 450 calories 450 calories/(9 calories/g) 50 g fat The diet prescription will be 190 g carbohydrate, 75 g protein, and 50 g fat. The amount of food from each of the exchange lists will be chosen to satisfy these nutrient requirements. Alcohol usage is determined by the attending physician. Because alcohol contains 7 calories per gram and no nutrients, it is usually substituted for fats in the diet. A chart showing the caloric content of individual servings of alcohol (one glass of wine or one glass of beer, for example) helps those diabetics who drink. 

CALORIC REQUIREMENTS 

Daily caloric need includes basal metabolism, activity rate, and physiological stress (such as a growth spurt or pregnancy). If the patient is overweight, the caloric range is usually 1200 to 1500 calories per day. If the patient is thin, young (growing), and male, it may be as high as 4000 calories per day. Tables 18-2A and 18-2B contain food plans at four caloric levels, using the exchange system. They also meet the nutrient balance concept, as previously discussed, of approximately 50% carbohydrate, 20% protein, and 30% fat. Complex carbohydrates containing good amounts of fiber are emphasized when menu planning is done, as well as the use of lean protein foods and very little animal fat. There are many ways to calculate daily caloric need for an adult diabetic patient. The methods include the three categories discussed in the following sections.

Tables or Charts Method:

Most healthcare providers such as medical clinics, weight loss centers, diabetic centers, and others use standard tables or charts that provide your daily caloric needs according to the standard variables such as race, age, sex, height, and physical activity. 

Ideal Weights and Basal Energy Needs Method 

For nearly four decades, health professionals have been using three fundamental assumptions based on available medical observation as a base of calculating daily caloric needs: 1. A table or chart has been developed to show the “ideal” or “desirable” weight of a man or a woman. 2. A person’s basal energy needs are generally figured at 1 kcal/kg body weight/hr. 3. Three levels of caloric expenditure have been developed for three levels of physical activity. An example is described below for calculating the daily caloric need of an adult patient: Patient’s desirable weight (DW) DW kg Caloric need for sedentary patient DW kg 20–25 kcal/kg Caloric need for patient with light activity DW kg 30 kcal/kg Caloric need for patient with strenuous activity DW kg 35 kcal/kg Special considerations are made for other groups: childhood, adolescence, elderly, with adjustment made if the person is overweight or underweight. As a result of new scientific studies, this method is not as popular as it once was. 

Individualized Method 

Scientifically, the most sophisticated method of calculating daily caloric needs uses many equations that cover several variables: race, age, sex, height, body mass index, and physical activity. This method is used mainly by large medical and research centers and applies to all age groups. However, for children and adolescents, the following individualized method is applicable and used frequently (for children, common estimates are based on age and sex): Up to 1 year: 120 kcal/kg of body weight 1–10 years: 100–80 kcal/kg (declines as age increases) Adolescence: Male 11–15 years: average, 65 kcal/kg body weight 6–20 years: average, 50 kcal/kg (high activity) 40 kcal/kg (light activity) 30 kcal/kg (sedentary) Female 11–15 years: average, 35 kcal/kg body weight 16–up years: average, 30 kcal/kg body weight However, of all methods mentioned previously, tables and charts are used by most clinics and healthcare providers. After the patient’s daily caloric need is determined, the physician (or dietitian) will prescribe the percentage of these calories from carbohydrate, protein, and fat, respectively. Then the permitted grams of these three nutrients can be calculated. 

NUTRIENT DISTRIBUTION 

When the daily amounts of protein, carbohydrate, and fat have been determined, they are converted into food servings and spread throughout the day into three meals and from one to three snacks, depending on the need for insulin injection, oral drugs, activity, or a combination of these. Large amounts of food, especially carbohydrates, should be avoided at any one time. A balance of meals throughout the day provides better control. The diabetic person should have regular meal hours to avoid fluctuations in blood glucose. 

FOOD EXCHANGE LISTS 

The exchange system of dietary control is widely used to manage the diet of a diabetic patient. This system permits flexibility in planning and preparation and allows measuring instead of weighing. It also offers a variety of food choices. However, the student will recognize, after studying the exchange lists, that it is not a suitable guide for planning meals for some ethnic groups or in all clinical situations. People from diverse cultural backgrounds may need nutrition counseling. Many times the illiterate or confused client will not understand the exchanges as written. Some clients have vision and/or hearing impairments. At such a time, students may wish to research the particular foods needed in order to individualize the diet or to simplify it. The dietitian in a nearby healthcare facility can be an excellent source for additional information, and can assist in designing appropriate diet instructions. The exchange system provides equivalent food value for each food within a list; for example: Starch list: B vitamins, iron, protein, and carbohydrate Meat list: iron, zinc, B12, protein, and varying fat contents Milk list: carbohydrate, protein, varying fat contents, folacin and other vitamins from the B complex, vitamins A and D, and minerals Vegetable list: vitamins A, E, C, and K; B complex; fiber; protein; and carbohydrate Fruit list: vitamins, minerals, carbohydrate, and fiber.

CARING FOR A DIABETIC CHILD 

Caring for a diabetic child requires many special considerations, some of which are listed below: 

1. Disease characteristics: 

        a. The patient may be normal or underweight. 

        b. Disease onset is abrupt and increases in severity during growth periods. 

        c. Pancreatic cells cannot make insulin, and a diabetic child is insulin dependent. 

        d. As the patient grows older, the requirement for insulin increases. 

2. Dietary treatment goals: 

        a. To permit normal growth and activity 

        b. To control the disease 

        c. To permit a normal school and social life with minimal restriction in freedom of movement and food choices 

        d. To correspond with the action of insulin treatment. To achieve the above goals, the diet must recognize the child’s food preferences and differ little from that of the patient’s peers. Also, the child must be provided adequate food to permit normal development and activities. 

3. Diet prescription and meal planning 

       a. 75–90 kcal/kg of the child’s ideal weight. 

       b. 3.3 to 2.2 g of protein per kg body weight, with decreasing amount for increasing age. 

       c. 50% of total calories from complex carbohydrate, 20% from protein, and 30% from fat. 

       d. Three meals and three snacks daily usually, with other meal patterns determined by patient’s clinical condition, amount of insulin needed, daily activities, and other factors. 

       e. Meal plan coordinated with activities—sweets and extra fluids for strenuous and prolonged activities, eating a prescribed snack just before an exercise. 

4. Patient compliance and education 

       a. A young diabetic will accept a diet if it is not too different from that of his or her peers, and if it permits the child freedom in school and play. 

       b. The patient should learn how to use the exchange lists for fast foods, which is included in the patient’s booklets for meal planning. This permits the child to eat fast foods with his or her friends without deviating from the dietary prescription.

Patient Education 

A diabetic person may become ill from causes such as infection, trauma, and so on. Patients with a shortterm illness should follow the guidelines indicated in Exhibit 18-1. The patient is the most important member of the healthcare team. His or her participation and cooperation must be gained. Who to Teach and How 

1. Teaching one patient instead of a group of patients is more useful to the patient, although it is more costly in time and money. 

2. If group education is used, patients should be sorted by their type of diabetes (e.g., young and insulin dependent diabetics, obese patients using OHAs, and patients who are maintaining by diet alone). This sorting reduces confusion in the teaching process. If feasible, the use of both individualized and group education is ideal. 

3. The benefits and limitations of using paraprofessionals to teach the patient should be considered. 

4. The patient’s history should be studied, especially the type of diet instructions he or she has previously received. This ensures that the patient will not receive contradictory information during an education session. Any information presented that seems to conflict with previous instructions should be explained to a patient’s satisfaction. 

5. At least one close relative or the patient’s caretaker should be familiar with the information presented to the patient and should be present for the teaching sessions. Some teaching aids and counseling services for diabetic persons include: Local, city, and county diabetic programs and support groups Private and public diabetic (clinical) centers Professional sources of materials include drug companies, American Dietetic Association, American Diabetes Association, state health agencies, diabetes educators Food models, films, and slides Ethnic teaching materials Demonstration kitchens and demonstration food portion sizes Recipes and cookbooks Evaluation and follow-up teaching by the nurse or a clinical nutrition specialist should be scheduled.