INTRODUCTION
Diabetes mellitus is one of the most common endocrine disorders. It is a disorder of metabolism of carbohydrate,protein and fat due to absolute or relative deficiency of insulin secretion and with varying degrees of insulin resistance. This metabolic disorder results in long-term disease specific microangiopathy (nephropathy,retinopathy, neuropathy) and aggravation of macroangiopathy.
CLASSIFICATION
Type 1 diabetes can occur at any age but usually develops in children or adults aged <40 years (previously referred to as insulin dependent diabetes, IDDM). This occurs as a result of lack of insulin production by the pancreatic B cells. It requires treatment with insulin and dietary management.
Type 2 diabetes is usually diagnosed in older adults but is increasingly seen in younger adults and some children (previously referred to as non-insulin dependent diabetes, NIDDM). It is associated with a lack of insulin function as a result of insulin resistance with or without insufficient production and is strongly associated with overweight and obesity. Dietary management is required, with or without oral hypoglycaemic agents or insulin.
Gestational diabetes is hyperglycaemia diagnosed during pregnancy that had not been previously diagnosed. Dietary advice is advisable and some patients may also require insulin.
DIAGNOSIS
Symptoms of diabetes plus Random blood glucose> 200 mg% (11.1 mmol/l)
Fasting plasma glucose > 126 mg% (7 mmol/l)
Two hour plasma glucose > 200 mg% during an oral glucose tolerance test.In the absence of unequivocal hyperglycaemia and acute metabolic decompensations these criteria should be confirmed by repeat testing on a different day.
Principles of the test: Give 150-200 gm of carbohydrate daily for 3 days prior to the test. Overnight fast is advocated the day before the test. Patient should take 75 g of glucose dissolved in 300 ml of water; Serum glucose should be measured every half an hour for 2 hours.
Islet cell antibodies are positive in about 80% of thepatients before administration of insulin.
C-Peptide: 24 hours urine collection is recommended.
In normal persons ‘c’ peptide level > 30 µg
In Type I diabetes < 10 µg
In Type II (obese with insulin resistance)> 60 µg
In type II with some insulin deficiency < 30 µg
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GOALS OF DIETARY MANAGEMENT
To maintain or improve health through the use of appropriate and healthy food choices.
To achieve and maintain optimal metabolic and physiological outcomes including:
reduction of risk for microvascular disease by achieving near normal glycaemia without undue risk of hypoglycaemia;
reduction of risk of macrovascular disease including management of body weight, dyslipidaemia, and hypertension.
To optimize outcomes in diabetic nephropathy and in any concomitant disorder such as coeliac disease or cystic fibrosis.
DIETARY GUIDELINES
Some of the dietary guidelines for diabetics are:
Daily energy intake must be estimated after considering such factors as age, sex, actual weight in relation to desirable weight, activity and occupation.
A diabetics should maintain standard body weight or slightly lower.
Three main meals and 3 between meal snacks can be taken avoid hypoglycemia.
Patients should avoid fasting and feasting.
Foods to be avoided
Simple sugars (glucose,honey, syrup),Sweets, cake, candy, fried foods, alcohol, jaggery, sweetened juices.
Foods to be eaten in moderation
Fats, cereals, pulses, meat, egg, nuts, roots, fruits like banana, mango, apple, custard apple, sapota, and artificial sweeteners.
Foods to be permitted
Green leafy vegetables, low glycemic index fruits, lemon, clear soups, spices, salads, plain coffee or tea, skimmed milk and buttermilk.
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GLYCEMIC INDEX
The glycemic index indicates the extent of rise in blood sugar in response to a food in comparison with the response to an equivalent amount of glucose. The ability of the food item to raise the blood sugar is measured in terms of glycaemic index.
Factors that affect the glycaemic response to food are:
• Rate of ingestion of food
• Food form
• Food components such as fat content, fiber content, protein content
• Method of cooking and processing food.
The glycaemic index is therefore useful in planning diet for diabetics.
Lower GI - Oats and oat products, pulses, peas, beans, legumes,pasta, unripe fruit, milk, and plain yogurt
Moderate GI - Rice, granary, pitta, and rye bread, new potatoes,muesli
Higher GI - White and wholemeal bread, wheat- and corn-based breakfast cereals, old potatoes, mashed potatoes, fruit juice, honey
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FOODS TO BE TAKEN
1. Non-Starchy Vegetables
Non-green, non-starchy vegetables like mushrooms, onions, garlic, eggplant, peppers, etc. are essential components of a diabetes prevention (or reversal) diet.
2. Green Vegetables
Higher green vegetable consumption is associated with lower risk of developing type 2 diabetes, and among diabetics, higher green vegetable intake is associated with lower HbA1c levels.
A recent meta-analysis found that greater leafy green intake was associated with a 14% decrease in risk of type 2 diabetes.
One study reported that each daily serving of leafy greens produces a 9% decrease in risk.
3. Nuts and Seeds
Low in glycemic load, nuts and seeds promote weight loss, and have anti-inflammatory effects that may prevent the development of insulin resistance.
4. Beans
Lentils, beans, and other legumes are the ideal carbohydrate source.They’re low in glycemic load due to their moderate protein and abundant fiber and resistant starch, carbohydrates that are not broken down in the small intestine.Accordingly, bean and legume consumption is associated with reduced risk of both diabetes and colon cancer.
5. Fresh Fruit
Rich in fiber and antioxidants, fruits are a nutrient-dense choice for satisfying sweet cravings.
Eating three servings of fresh fruit each day is associated with an 18% decrease in risk of diabetes.
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FOODS TO BE AVOIDED
1. Added Sugars
Diabetes is characterized by abnormally elevated blood glucose levels.Fruit juices and sugary processed foods and desserts have similar effects. These foods promote hyperglycemia and insulin resistance.
2. Refined Grains
(White Rice and White Flour Products)Carbohydrates like white rice, white pasta, and white bread are missing the fiber from the original grain. So they raise blood glucose higher and faster than their intact, unprocessed counterparts.
3. Fried Foods
Potato chips, French fries, doughnuts, and other fried starches start with a high-glycemic food, and then pile on a huge number of low-nutrient calories in the form of oil.
4. Trans Fats (Margarine, Shortening, Fast Food, Processed Baked Goods)
Diabetes accelerates cardiovascular disease. Because the vast majority of diabetics (more than 80%) die from cardiovascular disease, any food that increases cardiovascular risk will be especially problematic for those with diabetes.
5. Red and Processed Meats
At first glance, it may seem like the dietary effects on diabetes would be only relevant to carbohydrate-containing foods. The more low-carbohydrate, high-protein foods in your diet, the better; those foods don’t directly raise blood glucose.However, that is a too simplistic view of the development of type 2 diabetes. Type 2 diabetes is not only driven by elevated glucose levels, but also by chronic inflammation, oxidative stress, and alterations in circulating lipids (fats).
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MANAGEMENT OF DIABETES WITH ORAL HYPOGLYCEMIC DRUGS
Oral Hypoglycaemic Drugs are anti-diabetic drugs designed to help people with type II diabetes to manage their condition. These drugs are used only in the treatment of type II diabetes, which is a disorder involving resistance to secreted insulin.
Classification: There are now four classes of Hypoglycemic Drugs.
1. Sulfonylureas
2. Metformin (biguanides)
3. Thiazolidine diones
4. Alpha-Glucosidase inhibitors
1. Sulfonylureas
These are the most widely used drugs for the treatment of type II diabetes and appear to
function by stimulating insulin secretion. These are valuable in the treatment of patients with type 2 diabetes who fail to respond to simple dietary restrictions and who are not overweight
2. Metformin (biguanides)
Biguanides, especially metformin, are categorized as insulin sensitizers because they reduce insulin stimulated liver glucose production. This is manifested as an improvement in fasting glucose values. Metformin is used for a patient with diabetes who is overweight and dietary restrictions are effective.
3. Thiazolidine diones:
These drugs reduce insulin resistance by binding to a nuclear peroxisome – Proliferation activated receptor gamma in muscle and adipose cells.
4. Alpha – Glucosidase inhibitors:
These inhibitors do not target the mechanisms underlying insulin resistance or deficient secretion.
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INSULIN THERAPY
GOALS:
1. Elimination of primary glycosuric symptoms
2. Prevention of DKA and hyperosmolar coma
3. Restoration of lost lean body mass
4. Improvement in physical performance
5. Improvement in sense of well being
6. Reduction of frequent infections
7. Decrease in foetal malformation, maternal and foetal morbidity
8. Delay, arrest or prevention of microvascular and
macrovascular complications of diabetes.
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Insulin analogue
Insulin aspart
Insulin detemir
Insulin glargine
Insulin lispro
REFERENCES
Oxford Handbook of Nutrition and Dietetics by Joan Webster-Gandy, Angela Madden, Michelle Holdsworth
Manual of Practical Medicine (Fourth Edition) by R Alagappan MD FICP
Essentials of Medical Pharmacology Seventh Edition KD TRIPATHI MD
https://foodrevolution.org/blog/how-to-eat-to-prevent-diabetes/
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