Before deciding what form of dietary intervention to make, a full evaluation of the past and present circumstances of the person with any disease or condition is necessary. Such an evaluation should take account of the following issues:
- The person’s previous experience of diabetes/Hypertension or any other condition
- Any prior diet education
- Their knowledge and self-care skills
- Their current situation:
- The prevailing clinical and psychological status
- Self-management practices (nutrition and treatment plans)
- Clinical goals (target blood glucose or weight or hormonal level or lipids)
- Nutrition goals
- Lifestyle factors
- Levels of physical activity
Most foods contain a combination of essential nutrients that can broadly be classified into two types:
A. Macro-nutrients – known as such because the body needs more of these – include proteins, carbohydrates and fats.
These nutrients are
- Oxidized in the body to provide energy
- Needed for reproduction
- Essential for cell repair and growth
B. Micro-nutrients – required in smaller amounts – include vitamins and minerals. Micro nutrients are needed for proper utilisation of macro nutrients and enable the body to produce enzymes, hormones and other substances essential for proper growth and development.
Adequate fluid and fiber are also essential to correct body
Energy is produced by the utilization of food in the body.
Awareness of the amount of nutritional energy contained in foods is important to meal planning:
Both kilocaloríes (kcal) and kilojoules (kJ) are common units used for describing the amount of energy liberated by foods
Energy requirements vary in different situations:
- People with obesity need to reduce their energy consumption
- Pregnant and lactating women need more energy (calories)
- People recovering from severe and prolonged illness also need higher caloric intakes
Carbohydrates are the main source of energy for the body. Aim for 45-60% of total energy from carbohydrates; however each person should be individually assessed.
A number of studies regarding the effect of the source of carbohydrates on blood sugar levels show little or no variation (when adjusted gram for gram). This means that sucrose may be included as part of the carbohydrate component in a planned diet.
- It is recommended that sucrose and refined carbohydrates are consumed within the context of a healthy meal to prevent obesity and dental caries.
- Starchy carbohydrates are a healthier carbohydrate option than sucrose and refined sugars.
- The amount and source of carbohydrates is considered in planning meals. It is recommended that carbohydrates come from whole grains, potatoes, pulses, fruit and vegetables and milk rather than from large amounts from sucrose or other refined sugars.
- Carbohydrates are found almost exclusively in plant foods, such as cereals, potatoes, pulses, fruits, vegetables.
- Pulses belong to the legume family – peas, beans, lentils.
- Milk and milk products, though rich in protein, also contain significant amounts of carbohydrates.
Proteins are an important constituent of tissues and cells in the body. They have many different functions:
- Provide the body with energy
- Supply the body with building material for growth and repair
- Needed for the production of hormones, antibodies, enzymes and tissues
Proteins are broken down into amino acids – the building blocks of body tissue.
Amino acids which cannot be synthesised in the body and are supplied in the diet are called "essential amino acids."
Proteins come from both animal and plant sources:
- Animals: egg, milk, meats, pork, fish, poultry, cheese, yoghurt (curd), cottage cheese (paneer)
- Plants: beans, legumes, tofu, nuts, seeds
Recommended Daily Intake for protein for adults is 0.8 g high-quality protein/kg body weight/day.
As animal protein is often high in fat, lean meats, skimmed milk and low fat milk products are preferred.
10-20% of total energy per day is acceptable (similar to general population).
For a person weighing, for example, 70 kg this would give a recommended daily intake of 56 g of protein/day.
It is important to explain carefully that the dietary recommendations for the intake of fats are broken down in the following way:
Individual meal plans vary, however the proportion of nutrients recommended remains the same.
Fat is a concentrated source of energy. It is an essential nutrient and plays several vital roles:
- It provides oil for the skin
- It regulates body functions by forming hormones
- It insulates and protects internal organs
- It carries fat-soluble vitamins throughout the body
- It helps repair damaged tissue and helps to fight infections
Dietary fats can be of two kinds: visible or invisible or some say added or hidden.
Added fats are cooking fats or oils like lard, butter, ghee, corn oil, olive oil, etc.
Hidden fats are those found in most natural foods like milk, oilseeds, nuts, egg, meat, etc.
Hidden fats are believed to contribute significantly to the fat content of the diet.
Total dietary fat provides 20-35% of daily caloric intake. However, important distinctions are made between the different types of fat in the diet:
- Polyunsaturated fatty acids (PUFA) should represent up to 10% of total fat intake
- Monounsaturated fatty acids (MUFA) are generally preferred, as they may enhance cardiovascular health
- Saturated fats should be minimised
- Trans fats and hydrogenated fats should be avoided
For this reason it is important for participants to consider local sources of monounsaturated fats.
Polyunsaturated fats help to reduce low density lipoproteins (LDL cholesterol or (LDL-C)) which is desirable, but may also lower levels of high density lipoprotein (HDL cholesterol or (HDL-C)) which is not desirable.
An excessive dietary intake of saturated fats can cause dsylipidaemia, especially raising the level of LDL-C (LDL “bad’’ cholesterol).
While they do not reduce the HDL-C, monounsaturated fats help lower LDL-C and triglycerides and are recommended.
Eating two or three portions of fish per week is recommended, one portion of which should be oily fish. The beneficial effects of eating fish can be lessened by cooking it in an unhealthy way, like deep frying or dressing with rich sauces.
Although oily fish is a popular source of omega-3 fatty acids, there are a number of other options for people living in areas where fish is not readily available.
Effect of dietary fat on lipid profile is as follows:
Dietary fat Total Cholesterol LDL
- PUFA Lowers Lowers
- MUFA Lowers Lowers
- Saturated Fatty acids Raises Raises
- Trans fat Raises Raises
Vitamins are essential to good health because they assist vital chemical reactions within cells.
- Vitamins can be found in balanced meals with plenty of fresh fruit and vegetables.
- The body stores only small amounts of water-soluble vitamins so regular daily intake is important.
- Cereals, pulses, fruits and vegetables are good sources of water-soluble vitamins.
- Sources of vitamins A, D, E, and K – all fat-soluble vitamins stored in body fat – include whole milk, butter, cheese, fatty fish, etc.
Supplementation is needed in cases of underlying deficiencies, such as:
- Pregnant/lactating women
- Elderly people
- People with strict energy restrictions
- Critically ill people
- People with kidney disease
- People with inadequate metabolic control
- People with nutritional deficiency
Here is a list of the minerals and trace elements that are necessary in varying amounts in the diet.
- Minerals: calcium, phosphorous, iron, sodium, potassium, magnesium
- Trace elements: iodine, zinc, copper, chromium, manganese, molybdenum, fluoride
- Other trace elements: selenium, cobalt, silicon, arsenic, nickel, vanadium.
The evidence currently available does not support mineral supplementation for all people with diabetes, although deficiencies of certain minerals, such as potassium, magnesium, and possibly zinc and chromium may aggravate carbohydrate intolerance.
People with underlying deficiencies will need supplementation.
The genetic makeup of people from different ethnic groups may require some supplementation.
“Antioxidant’’ is a classification given to several organic substances thought to help prevent the kind of cell and tissue damage that could lead to disease. They do this by neutralising the “free radicals’’ that cause damage to cells.
Free radicals are a natural by-product of processes within and among cells, though they can also be produced by exposure to various environmental factors, such as tobacco smoke and radiation.
Evidence suggests that antioxidants are important to good health since an excessive presence of free radicals in the body can lead to various complications, such as heart disease and cancer.
What are antioxidants?
- Vitamins C and E
- Vitamin A (which is converted from beta-carotene)
- Selenium (a mineral)
- A group known as the flavonoids
Common sources of antioxidants include:
- Tocopherols - wheat germ, nuts (almonds, walnuts and peanuts), seeds, whole grains, green leafy vegetables, vegetable oil like safflower oil, corn oil and fish-liver oil
- Carotenoids - carrots, squash, broccoli, sweet potatoes, tomatoes, kale, collards, cantaloupe, mango, peaches and apricots
- Vitamin C - citrus fruits, green peppers, broccoli, green leafy vegetables, strawberries, raw cabbage and potatoes
- Flavonoids - broccoli, pomegranate, lime, soya bean, oranges, lemons, apples, white grapefruit, onions, and chocolate
The evidence currently available does not support mineral supplementation for all people with diabetes, although deficiencies of certain minerals, such as potassium, magnesium, and possibly zinc and chromium may aggravate carbohydrate intolerance.
9. There are two types of fibre: soluble and insoluble.
For people with diabetes, there are various benefits of fibre.
Soluble fibre helps slow down the absorption of glucose and reduces the absorption of dietary fats.
Insoluble fibre provides bulk to food and therefore high fibre foods generally have fewer calories.
Insoluble fibre is important for the diet as it retains water, resulting in softer and bulkier stools that prevent constipation and haemorrhoids.
A high fibre diet may reduce the risk of colon cancer and vascular disease.
A diet containing both soluble and insoluble fibres from a wide variety of food sources is recommended for people with diabetes.
Neither soluble nor insoluble fibres are digested or absorbed into the blood stream.
Soluble fibre helps lower plasma lipid concentration. Insoluble fibre passes through our intestines largely intact and is excreted.
It is important for people with high fibre diets to drink adequate amounts of water.
10. Water is an essential nutrient to proper body functioning. It helps to regulate body temperature and to transport nutrients and waste products into and out of the cells.
Water is also needed in
- Digestion
- Absorption
- Circulatory and excretory functions
- The utilisation of water-soluble vitamins
11. Sodium is often referred to as salt. Salt intake across the entire population is too high.
Lower levels are recommended for all, and especially for people with diabetes. As hypertension is a recognised risk factor for diabetic nephropathy and cardiovascular disease, sodium control and restriction is important for people with diabetes.
Most sodium comes in processed/preserved/bakery or restaurant foods, the salt you add at the table or in cooking is a very small percentage of the whole.
Targets for daily sodium intake for different age groups:
AGE Adequate intake(mg/day) Upper limit (mg/day)
- 14-50 1500 (around 1 teaspoon salt) 2300
- 21-70 1300 2300
- Over 70 1200 2300
Fruits and vegetables are low in sodium and also higher in potassium, a factor in reducing the risk of high blood pressure). If fresh fruits and vegetables are not available use frozen products.
Ask for nutrition information at restaurants to see how much sodium is in the food on their menu. Many chains now make nutrition information available online or in the restaurant.
Nutritional advise to be continued in next article…………….