24 Nutrition Counseling for Diabetic Patients

Introduction

Diabetes mellitus is a common disease in the pop- ulation and it is clearly recognized that patients with diabetes have an increased risk for coronary heart disease. Indeed, several studies have shown that diabetic subjects have a two to four times greater risk of developing and dying from coro- nary heart disease than non-diabetic persons.

The estimated prevalence of diabetes among adults is, at present, situated between 8% and 10%

in the United States and between 6% and 7% in Europe. Prevalence of diabetes in patients hospi- talized for acute coronary event is between 38%

and 45%.

Therefore, it is not surprising that the percentage of diabetic patients enrolled for cardiac rehabilitation after an acute coronary event is high.

Nutrition counseling is an integral component of diabetes management and is an important part of the comprehensive educational program, during cardiac rehabilitation, in diabetic patients.

Criteria for the Diagnosis of Diabetes

According to the WHO, the ADA (American Diabetes Association), the IDF (International Diabetes Federation), and the ALFEDIAM (Asso- ciation de Langue Française pour l’Etude du DIAbète et des maladies Métaboliques),

the cri- teria for diagnosis are:

• fasting plasma glucose ≥126mg/dL (7.0 mmol/L), on two occasions

• or, 2-hour post oral load (75 g) glucose

≥200mg/dL (11.1mmol/L)

• or, symptoms of diabetes (such as polyuria, polydipsia, weight loss) and casual plasma glucose level ≥200mg/dL.

Two other glucose metabolism abnormalities exist: IGT (impaired glucose tolerance) and IFG (impaired fasting glucose). Both IGT and IFG are associated with increased cardiovascular risk.

Impaired glucose tolerance or IGT is defined by:

• 2-hour post oral load (75 g) glucose ≥140mg/

dL (7.8 mmol/L) and less than 200 mg/dL (11.1 mmol/L)

Impaired fasting glucose or IFG is defined by:

• fasting plasma glucose ≥110mg/dL (6.1mmol/L) and less than 126 mg/dL (7.0 mmol/L) for the WHO, IDF, and ALFEDIAM recommenda- tions

• fasting plasma glucose ≥100mg/dL (5.5mmol/L) and less than 126 mg/dL (7.0 mmol/L) for the ADA recommendations.

More recently, criteria for the diagnosis of a syndrome of insulin resistance close to type 2 diabetes, the metabolic syndrome, have been defined. According to the experts of the National Cholesterol Education Program (NCEP)-Adult Treatment Panel (ATP)-III, three of the following five items are needed for diagnosis of metabolic syndrome

:

• waist circumference >102cm in men and >88cm in women

24

Nutrition Counseling for Diabetic Patients

Bénédicte Vergès-Patois and Bruno Vergès

194

• plasma triglycerides ≥150mg/dL (1.7mmol/L)

• HDL cholesterol <40mg/dL (1.0mmol/L) in men and <50mg/dL (1.3mmol/L) in women

• blood pressure ≥130/85mmHg

• fasting blood glucose ≥110mg/dL (6.1mmol/L).

Nutrition counseling for patients with the meta- bolic syndrome is described in Chapter 25. As far as diabetes mellitus is concerned, three kinds of diabetes exist:

• Type 1 diabetes due to pancreatic beta-cell destruction leading to absolute insulin defi- ciency. The major cause of type 1 diabetes is autoimmune destruction of the beta-cells of the pancreas.

• Type 2 diabetes, due to the combination of insulin resistance and relative insulin deficiency.

This form is the most frequent type of diabetes.

• Other specific types of diabetes, including diseases of the exocrine pancreas, endo- crinopathies, acromegaly, Cushing’s syndrome, drug- or chemically induced diabetes, genetic defects of the beta-cell, genetic defect in insulin action.

Nutrition Guidelines for Diabetes

The American Diabetes Association (ADA) and the ALFEDIAM have published nutrition guide- lines for patients with diabetes that are summa- rized here.

Energy Balance

Energy intake does not have to be modified in diabetic patients when their weight is normal.

However, since obesity is frequent in patients with type 2 diabetes, weight loss is an important ther- apeutic objective in many type 2 diabetic patients.

Indeed weight loss in subjects with type 2 diabetes is associated with decreased insulin resistance and improvement of glycemia, lipid profile, and blood pressure. A moderate decrease in caloric intake (500–1000 kcal/day) will result in slow but pro- gressive weight loss. For most patients weight loss diets should supply at least 1000–1200 kcal/day for women and 1200–1600 kcal/day for men. In order to lose weight, fat is the most important nutrient to restrict. Physical activity is also an important

component of a comprehensive weight manage- ment program.

Carbohydrates

The recommended range of carbohydrate intake is 45–65% of total calories. Both the amount (grams) of carbohydrates and the type of carbo- hydrate in a food influence blood glucose levels.

However, with regard to the glycemic effects of carbohydrates, the total amount of carbohydrate in meals or snacks is more important than the source or type. Monitoring total grams of carbohydrate, whether by use of exchanges or carbohydrate counting, remains a key strategy in achieving glycemic control. The use of the glycemic index (a measure of the glycemic effect of types of carbohydrate) can provide an addi- tional benefit over that observed when total carbohydrate is considered alone. Low carbo- hydrate diets (restricting total carbohydrate to

<130 g/day) are not recommended in the management of diabetes.

Carbohydrates are recommended in each meal of the day. Foods containing carbohydrates from whole grains, fruits, vegetables, and low-fat milk should be included in the diet. Like the general population, patients with diabetes are encouraged to consume fiber-containing foods (such as whole grains, fruits, and vegetables) because they provide vitamins, minerals, fiber, and other sub- stances important for good health. However, there is no reason to advise people with diabetes to consume a greater amount of fiber than non- diabetic individuals.

As sucrose does not increase glycemia to a greater extent than isocaloric amounts of starch, sucrose and sucrose-containing foods do not need to be restricted by people with diabetes. However, they should be substituted for other carbohydrate sources in the diet. Non-nutritive sweeteners (saccharin, aspartame, acesulfame potassium and sucralose) are safe when consumed within accept- able daily intake levels.

Lipids

The recommended range of fat intake is 30–35%

of total calories. One of the primary dietary fat

goals in patients with diabetes is to limit saturated

fat intake. Many studies have shown that diets low in saturated fat decrease plasma LDL cholesterol and reduce cardiovascular disease. Thus, it is rec- ommended in patients with diabetes, as in the general population, to reduce dietary saturated fats less to than 10% of energy intake. In persons with plasma LDL cholesterol ≥100mg/dL, the sat- urated fat intake should be reduced to less than 7%. Polyunsaturated fat intake should be 10% of energy intake. Among foods containing polyun- saturated fat, those containing n-3 polyunsatu- rated fatty acids (such as fish) are recommended, since they lower plasma triglycerides in type 2 diabetic patients and have been shown, in the general population, to have cardioprotective effects. Thus, two or three servings of fish per week are recommended in persons with diabetes.

The consumption of monounsaturated fat should be between 10% and 20% of energy intake. Plant sources that are rich in monounsaturated fatty acids include vegetable oils (e.g. olive, canola, sunflower oils) and nuts.

Moreover, dietary cholesterol intake should be less than 300 mg/day. Indeed, reduction of dietary cholesterol intake decreases plasma LDL choles- terol. Furthermore, persons with diabetes appear to be more sensitive to dietary cholesterol than the general population. The intake of trans fatty acids should be minimized as the effect of trans fatty acids is similar to that of saturated fats in raising plasma LDL cholesterol. Trans fatty acids also lower plasma HDL cholesterol. The main sources of trans fatty acids in the diet include products made from partially hydrogenated oils such as baked products, cookies, and pies.

The “Carbohydrate–Monounsaturated Fat Balance”

Carbohydrate and monounsaturated fat together should provide 60–70% of energy intake. The metabolic profile of the patient and the need for weight loss should be considered when determin- ing the proportion of carbohydrate and monoun- saturated fat intake. Indeed, high-carbohydrate diets increase postprandial levels of glucose and triglycerides and, in some studies, decrease plasma HDL cholesterol level when compared to isocaloric high-monounsaturated fat diets. On the other hand, high-monounsaturated fat diets may

result in increased energy intake and weight gain.

Therefore, when weight reduction is the major goal in a diabetic patient reducing monounsatu- rated fat intake is preferred, thus increasing the relative carbohydrate intake. When the metabolic profile of the diabetic patient is the major concern, reducing carbohydrate intake is recom- mended, increasing the relative monounsaturated fat intake.

Proteins

The recommended protein intake in patients with diabetes is 15–20% of energy intake, if renal function is normal. This proportion is similar to the usual protein intake in the general population.

Minerals and Vitamins

A daily intake of 1000 to 1500 mg of calcium is rec- ommended. This recommendation appears to be safe and likely to reduce osteoporosis in older persons. There is no clear evidence of benefit of vitamin or mineral supplementation in people with diabetes who do not have underlying deficiencies.

Alcohol and Diabetes

The same precautions apply regarding the use of alcohol as in the general population. Abstaining from alcohol should be advised for people with other medical problems such as pancreatitis, advanced neuropathy, severe hypertriglyc- eridemia, or alcohol abuse. If individuals choose to drink alcohol, daily intake should be limited to one drink per day for adult women and two drinks per day for adult men.

Special Considerations for Type 1 Diabetes

Nutrition recommendations for a healthy lifestyle

for the general public

are also appropriate for

persons with type 1 diabetes. Since the body

weight of patients with type 1 diabetes is usually

normal, energy intake does not have to be

modified. Many type 1 diabetic patients are now

treated with intensive insulin therapy (insulin

pumps or basal-bolus insulin regimen). For these

should eat more servings of grains, beans, and starchy vegetables than of any of the other groups.

The smallest group (fats, oils, sweeteners, and alcohol) is at the top of the pyramid, which means that only a few servings from this group are receommended.

Bread, Grains, and Other Starches

At the base of the pyramid are bread, cereal, rice, and pasta. These foods contain mostly carbohy- drates. The foods in this group are made mostly of grains, such as wheat, rye, and oats. Starchy veg- etables (like potatoes, peas, and corn) and dry beans also belong to this group because they have about as much carbohydrates in one serving as a slice of bread. Starchy vegetables and dry beans also provide vegetable proteins.

All grains and starches contain carbohydrates.

However, their glycemic index (a measure of the glycemic effect of the type of carbohydrate) may be different according to the type of food and the cooking preparation. For instance, mashed pota- toes have a higher glycemic index than unmashed potatoes and pasta “al dente” has a lower glycemic index than overboiled pasta.

Vegetables and Fruits

Five servings of fruits or vegetables are recom- mended each day in patients with diabetes.

Most vegetables are naturally low in fat and are good choices to include often in meals or to have as a low-calorie snack. Vegetables are full of vita- mins, minerals, and fiber. This group includes spinach, chicory, lettuce, broccoli, cabbage, Brus- sels sprouts, cauliflower, carrots, tomatoes, cucum- bers, French beans, etc.

Fruits have plenty of vitamins, minerals, and fiber. They also contain carbohydrates. This group includes blackberries, strawberries, oranges, apples, bananas, peaches, pears, apricots, grapes, etc. Some fruits such as grapes and cherries have a higher glycemic index than other fruits.

However, the glycemic index of fruits is attenuated when fruits are consumed at the end of a complete meal.

Some vegetables such as olives or avocados and some fruits such as nuts also contain monounsat- urated fats.

patients, the total carbohydrate content of meals (and snacks) is the major determinant of the premeal insulin dose and the postprandial glucose response. Thus, patients treated with intensive insulin therapy are advised to adapt the premeal insulin dose to the carbohydrate content of the meal.

For planned exercise, reduction in insulin dosage may be the preferred choice to prevent hypoglycemia. Additional carbohydrate may be needed for unplanned exercise. For instance, a 70 kg person would need between 10 and 15 g carbohydrate per hour of moderate physical activity.

Practical Recommendations

For practical purposes, the ADA Diabetes Food Pyramid is recommended (Figure 24-1).

This pyramid divides food into five groups.

The largest group (breads, grains, and other starches) is on the bottom. This means that one

Meat, Meat Substitutes and Other Proteins

Fruits Milk

Fats, Oils and Sweets

Vegetables

Breads, Grains and Other Starches

FIGURE24-1. The ADA (American Diabetes Association) Diabetes Food Pyramid.

Milk and Dairy Products

Milk products contain a lot of protein and calcium as well as many other vitamins. Since a daily intake of 1000 to 1500 mg of calcium is recom- mended, the advice is to consume milk or dairy products three times a day. Non-fat or low-fat dairy products (milk, yoghurt, etc.) should be chosen to reduce saturated fat.

Meat, Meat Substitutes, and Other Proteins

This group includes beef, chicken, turkey, fish, eggs, tofu, cheese and cottage cheese. Meat and meat substitutes are good sources of protein and many vitamins and minerals. The fattest meat such as mutton and beef should be limited because they are rich in saturated fat; lean meat such as chicken or turkey would be preferred.

Pork-butchery products are rich in protein.

However, many of them (for instance, sausages, lard) contain large amounts of saturated fat. Ham and bacon that have less than 10% of saturated fat should be preferred.

Two or three servings of fish per week are recommended because fish provides proteins and n-3 polyunsaturated fatty acids. Indeed, n-3 polyunsaturated fatty acids lower plasma triglyc- erides in type 2 diabetic patients and have been shown, in the general population, to have cardio- protective effects.

Cheese provides protein and calcium but is rich in saturated fat. Thus, it is recommended to limit the amount and to choose low-fat cheese.

Fat, Oil, Sweets, and Alcohol Fat

Many foods contain fat as we have previously dis- cussed (for instance, cheese, meat). We also use fats for cooking such as butter and oil. Fat is calorie-dense: per gram, it has more than twice the calories of carbohydrate or protein. Since over- weight is frequent in patients with type 2 diabetes, the amount of fat should be limited in order to lose weight or to maintain a healthy weight.

Foods that contain saturated fats, such as butter or some vegetable oils (palm oil), must be used in small amounts. Instead of butter, skimmed cream could be used.

Oil

Since foods containing mono- and polyunsatu- rated fats must be favored in patients with dia- betes for their cardioprotective effects, a good choice for cooking should be olive or groundnut oils rich in monounsaturated fats and colza or nut oils rich in n-3 polyunsaturated fatty acids. Foods like potato chips, candy, cookies, cakes, crackers, pastries, and many ready-cooked dishes contain excessive amounts of fat or sugar, so they must be limited to small servings and saved for a special treat!

Sweets

Except in hypoglycemia, sweet products are not recommended in patients with diabetes due to their high glycemic index. Sodas and some con- centrated fruit juices can be very rich in sugar. It is possible to substitute sodas with diet drinks, and concentrated fruit juices with pure fruit juices with no sugar added.

Alcohol

Intake of alcohol should be limited to one glass a day (100 mL) for women and two glasses a day for men except when contraindications are present, as we have seen previously. Beer, which contains sugar and alcohol, must be avoided in patients with diabetes. Moreover, it increases plasma triglyceride levels.

Useful Nutritional Tips for Diabetic Patients

Cooking Tips

Here are some ideas to help patients with diabetes to make healthy recipes. It is recommended:

• to reduce fat in baked products

• to use olive, groundnut, colza or nut oils or unsaturated fat margarines instead of butter

• to use skimmed milk instead of whole milk

• to skim the fat off meat and opt for broiling or roasting rather than frying

• to reduce the amount of sugar in baked foods

and desserts. Non-nutritive sweeteners may

be used to replace sugar. It is also possible

to add spices to increase the flavor in addition to reducing the amount of sugar in the recipes.

Take a Closer Look at the Label

To make wise food choices at the grocery store, diabetic patients must take an attentive look at the labels and the list of ingredients in the products. The information on the label provides total amounts of different nutrients per serving. Total amounts are shown in grams (g) or in milligrams (mg). Therefore, it is advised:

• to check the total amounts of calories, total fat, total carbohydrate and sugar alcohols

• concerning fat, to look precisely at the propor- tion of saturated and trans fats and of mono- and polyunsaturated fat

• concerning carbohydrates, to note the percent- ages of sugar, complex carbohydrates and fiber

• concerning “sugar-free” products, to look for the type of sweeteners used. Non-nutritive sweeten- ers (saccharin, aspartame, acesulfame potas- sium, and sucralose) are safe to consume. The sugar alcohols (xylitol, mannitol, and sorbitol) have some calories and do slightly increase plasma glucose. Eating too much of them can cause intestinal complaints. Patients should also be advised that some “sugar free” or low- carbohydrate products are richer in fat than usual products.

Guide to Eating Out

Eating out is a part of our lives (business meet- ings, meals with friends, fast-food with the chil- dren), often leading to the consumption of much more than at home, with more calories, sugar, and fat! Some tips are needed to order a healthy meal.

It is advised to keep in mind the rules of good nutrition, to know the nutritional value of the foods you order, and to try to eat the same portion as you would at home. It is very important to watch calories, especially if it is necessary to lose weight. Many restaurants are trying to meet health needs. Some of them offer foods lower in fat, sugar, salt, and cholesterol, and diet drinks. A variety of choices will increase the chances of finding healthy foods.

When having a meal at a restaurant, it is recommended to avoid fried foods and choose broiled or roasted vegetables, meat or fish and with no extra butter. Ask for sauces and salad dressings to be served on the side. We advise the substitution of high-calorie foods with more favorable nutrients (e.g. vegetables instead of French fries) and limiting alcohol, which adds calories but no nutrition.

Larger portions mean more calories, fat, salt, sugar! Thus, when having a fast-food meal, it is recommended to watch out for words such as

“giant, super-sized, double burger.” It is suggested to fill salads with a lots of different vegetables full of good nutrients and to end the meal with sugar- free, fat-free yoghurt.

When having a meal out, diabetic patients should choose healthier foods like fruits and veg- etables for the other meals of the day and increase their physical activity.

Nutrition counseling is important for patients with diabetes. It should not mean being restricted to a boring diet. Nutrition counseling in diabetic patients leads to a healthy and pleasant diet allowing a wide variety of food and a normal social life.

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