Diet In Diabetes

Authors: Dr S K Misra, Dr Menaal K, Dr S Sachdeva

Introduction:

Before the advent of oral hypoglycemic agents, the primary aim of glycemic control
was attempted at, by reducing dietary carbohydrate intake so that demand on
endogenous insulin is reduced.

In 1970’s, complex carbohydrates attracted the attention of researchers and a new

wave up surged advocating dietary management of diabetes with complex
carbohydrate rich diet. The complex carbohydrates promised the benefits of low
glycemic index as well as high fiber content. But after years of consuming such a diet,
neither the prevalence of diabetes in the community reduced nor did the rate of
complications among the diabetic population declined.

This led to an unsatisfied hunger for the search of a newer diet regimen for the
diabetic population, and especially for those with obesity. The concept of weight
management paved the way for introduction of ketogenic diet, which led to a
significant improvement in the insulin sensitivity.

But the game was yet not over, decreasing the calories intake meant an overall
decrease in the food consumption with the fear of micronutrient deficiencies. Also,
which macronutrient component can be afforded to be cut down on, was question of
extensive debates. In the backdrop, a better understanding of the role of unsaturated
fats, particularly of MUFA was directing the focus on low carb high fat diet. Omega 3
and omega 6 discoveries have further magnetized the focus on the “high- fat,
ketogenic diet” as the newer way of managing dietary patterns in diabetes.

Thus, in the present day before working out a proper diet plan for your patient, it is
advisable that you would first categorize the patient in to non- obese, overweight and
obese categories, to calculate the caloric requirement accordingly:

Steps in approaching the Diabetic Patient for a new diet plan:

I. Categorize the Patient:

Although obesity can be identified at the first sight, but when a diabetic
patient enters in the clinic, the physician should precisely categorize him as
obese or non-obese diabetic, using one of the convenient criteria:
 A. According to Body mass Index:

Body mass index (BMI)= weight in kg/ (Ht in m)2

BMI does not distinguish between weight associated with muscle mass and that with
fat content. Across different racial groups, the amount of fat varies among people
with same BMI. Thus, a BMI criterion for obesity among the Asian phenotype is
different due to a higher propensity of the Indian race to suffer metabolic syndrome.
Asians are prone to higher amount of fat, (especially visceral fat) than the amount of
muscle mass as compared to Non Asians with the same BMI.
So the Asian criteria is suggested to be narrower than the Global criteria

Underweight Normal Overweight Obesity

WHO <18.5 18.5- 24.9 25- 29.9 >30
Criteria
Proposed <18.5 18.5-22.9 23- 24.9 >25
Indian
Criteria

Similarly, women tend to have more fat mass than their male counterparts at the
same BMI value.

B. Ideal body weight

The aim is to achieve the ideal body weight, calculated according to the person’s height.

During every appointment, the patients must be motivated to strive to attain the ideal
body weight as the entire aim of dietary management is to draw the patients closer to
their individualized ideal body weight, so as to minimize the risk of Diabetes
complications

Brocca Index Males Females

Ideal Body Weight (Ht. in cm- 100) (Ht. in cm- 100) x 0.9

C. Central Obesity and Waist circumference

Studies reflect that Intra abdominal (visceral) fat contains more cells per unit mass,
more cortisol receptors, more androgen receptors and more blood flow as compared
to the sub cutaneous fat. Thus visceral fat distribution carries a worst outcome than
the subcutaneous fat in terms of risk to metabolic syndrome. The gold standard to
assess the visceral fat deposition is dual X‐ray absorptiometry (DEXA) scan, which is
not possible routinely in the clinical settings. However, in its place proxy markers for
the amount of visceral fat includes:
 Waist circumference: It is measured at mid-point between lower border of rib
cage and the iliac crest.
 The level of LDL and TGs in the blood

Men Women
WHO Indian WHO Indian
Waist >102 >90 cm >88 cm >80 cm
Circumferenc cm
e
Waist- Hip ≥1.0 ≥0.90 ≥0.85 ≥0.80
Ratio (WHR)

Thus to formularize a tailor made diet for every patient, the clinician may need to
measure waist and hip circumference along with weight and height of the individual
patient.

II. Calculate Daily Calories Required for the Individual Patient

If the patient has an ideal body weight, then the physician should advise him a
maintenance diet:

Recommended Caloric Intake for Non- Obese Diabetic Patients

Gender Caloric requirement per day

Sedentary females 35x present body weight

Sedentary males 39*x present body weight

(* for convenience and quick calculation, it can be rounded off to 40)

Recommended Caloric Intake for Obese Diabetic Patients

For overweight and obese patients, it is recommended that the a ketogenic diet be
planned to lower the caloric intake to an amount as follows:

Gender Recommended Caloric intake per day for the

obese/ overweight patient
Sedentary females 35x present body weight minus (5 to 10%, to a
maximum of 500Kcal)
Sedentary males 39 x present body weight minus (5 to 10%, to a max
 of 500Kcal)

A diet with low calories will set the body to use its glycogen and fat stores, thus
decreasing the weight of the patient as well as reducing the Insulin Resistance. But a
sudden crash in diet with deficit more than 500 Kcal should be avoided, because that
can lead to a rebound weight gain, partly attributable to non-compliance.
During every visit, the diet should be re-planned based on the weight of the patient on
that visit

III. The caloric break-up

While scheduling the diet for the patient, it should be emphasized that:

1. To reach the calculated caloric landmark Carbohydrate consumption should be

reduced more than the reduction of fat content, so that over a period of few weeks
to months the diet be transformed to a low caloric (mildly ketogenic) low carb high
‘good fat’ (Mono-unsaturated fatty acids or MUFA) diet with adequate amounts of
dietary fibers, anti-oxidants and micronutrients.

a. Carbohydrates (45-55%)- preferably constituting low – moderate

glycemic indexed food with high fiber content should be taken
b. Protein (10- 15%): ICMR guidelines recommends proteins from
vegetable sources, legumes, low fat milk and milk products & lean meat
(Fish and chicken breast piece) instead of red meat (mutton, beef, pork)
c. Fats (30- 35%)- preferably rich in Mono unsaturated fatty acids. MUFA:
may provide 10-20 % of total energy, while Poly unsaturated fatty acids
(PUFA): should provide upto 10 % of total daily energy intake with an ideal
omega 3: omega 6 ratio of 1:1 to 1:4. The saturated fats should be kept to a
low of <7% energy requirement.

Nutrient Proportion of Dietary Calories

Provided
Carbohydrates* 45- 55%
Proteins* 10- 15%
Fats*: 30- 35%
 Saturated Fats( < 7%
 MUFA (Mono-unsaturated fatty acids) 10- 20%
 PUFA(Poly-unsaturated fatty acids) 10%
 Omega3: Omega 6 ratio 1:1 to 1:4

*1gm Carbohydrate provides 4 Kcal, 1 gm Protein provides 4 Kcal and1 gm fat

provides 9 Kcal
 Thus, in practical implication, for a 60 kg non- obese diabetic male, calories needed
will be 39X 60 Kcal= 2340 Kcal per day. Of this, 45- 55% i.e. about 50% of 2340
Kcal= 1170 Kcal (so, 293 gm carbohydrates) should be obtained from complex
carbohydrates with low to moderate glycemic index;10- 15% i.e. about 12.5% of
2340 Kcal= 292 Kcal (73 gm proteins) from proteins preferably from plant sources
and lean meat. And 30- 35% of 2340 Kcal i.e. about 33.5% of 2340 Kcal= 784 Kcal
(87g of fats and oils) from Fats, such that most of it comes from MUFA rich oils and
nuts followed by omega 3 rich.
Consumption of Saturated fat should be kept to as low as <7% of total caloric
consumption, which means <7% of 2340 Kcal= 163 Kcal= 18gm, i.e. less than 4
teaspoons per day of ghee

It is advised that the total dietary calories should be broken down into 6 small
meals, instead of 3 major meals such that:

Breakfast 20% of energy need

Mid day snack 10% of energy need

Lunch 25% of energy need

Mid evening Snack 10% of energy need

Dinner 25% of energy need

Bed time Snack 10% of energy need

A brief Overview on the various Dietary components:

Carbohydrates

The Glycemic Index (GI)

The glycemic index (GI) is a ranking of carbohydrates on a scale from 0 to 100
according to the extent to which they raise blood sugar levels in comparison to
same amount of carbohydrate in pure glucose. For example, a baked potato has
a glycemic index of 76 relative to glucose, which means that the blood glucose
response to the carbohydrate in a baked potato is 76% of the blood glucose
response to the same amount of carbohydrate in pure glucose.
Carbohydrates with a low GI value (55 or less) are more slowly digested,
absorbed and metabolized and cause a lower and slower rise in blood glucose.
So it was being extensively advised to replace high glycemic index
carbohydrate with low to moderate glycemic index carbohydrates.
But recent trials have failed to show any long-term benefit of Low
glycemic index diet, in controlling blood glucose level. In essence, more
than the required amount of carbohydrates, (whether low or high in
glycemic index), can lead to poor glycemic control. Thus what actually
matters is the proportion of calories drawn from carbohydrates in every
meal, rather than the type of carbohydrate. This introduces the concept
of Carbohydrate Counting also known as “Carb Counting”

But most of the low glycemic food is rich in complex carbohydrates, associated
dietary fibers and micronutrients essential for overall health. Thus we
recommend consumption of such diet, but in an adequate amount.

Low Glycemic Index Moderate Glycemic High Glycemic Index

(<55) Index (56- 69) (70- 100)
Apples, Pineapple, Watermelon, Sharifa, grapes,
Apricots, papaya, pomegranates, mango, banana,
kiwi, peach, plum, raspberry, melons chiku, litchi, fruit
pears, prunes, juices
carrots, dry fruits,
hazel nut
Besan, Rye, Sprouted Whole wheat, white Maida, pizza, pita
grains, multi grain rice, yam, corn, tofu, bread, burgers,
flour, barley, tapioca, spaghetti, french fries, sweet
porridge, Dosa, cookies, potato, potato
Semolina, Bajra, Bran, kheer, pumpkin,
Coconut water, puttu, raisins, oats,
lentils, brown rice, muesli,
parboiled rice, pulses,
beans, peas,
mushrooms, pongal,
cheela, chappati,
Yoghurt, boiled egg, Milk Shakes
fish (Tuna, Salmon),

Highest (100%) Glycemic Index substances like sugar, khand, jaggery(gurd)

must not be taken. Tea coffee, milk and other beverages can be sweetened by
aspartame (sugar free), though the role of “sugar free” is also questionable

Glycemic Load (GL) is a measure of both the quality (the GI value) and quantity
(grams per serve) of a carbohydrate in a meal. A food’s glycemic load is
determined by:
 Glycemic Load = GI x Carbohydrate (g) content per serving ÷ 100

Similar to the glycemic index, the glycemic load of a food can be classified as low,
medium, or high:

Low: 10 or less
Medium: 11 – 19
High: 20 or more

However, the simplest way to use the GL is to choose foods with the lowest GI
within a food group or category, and to be mindful of your serve size.
For example, glycemic load of a bowl of brown rice constitutes= approx.
(<55)X 30g (dry weight) ÷ 100= less than 16.5 (i.e. medium glycemic load
food) whereas 2 bhaturas made of maida constitute a glycemic load of >70X 2X
25g (i.e.25g dry weight of each maida ball)÷ 100= more than 35 (i.e. high
glycemic load food)
Hence a bowl full of brown rice has moderate glycemic load (<16.5) and is
preferred over two Bhaturas with a high glycemic load (>35)

Non Digestable Carbohydrates: The Dietary Fibers

A daily intake of diet rich in fibers (legumes, fruits and vegetables) should be
ensured: 1-2 servings of different fruits and 2-3 servings* of vegetables daily is
advised. Fruits and vegetables provide not just the soluble & insoluble fibers but
also a variety of natural anti-oxidants and micronutrients essential for health.

*1 serving of fruits or vegetables= approx. 100 g (uncooked, cleaned)

* 1 serving of pulses or cereals= 25 g (dry weight)

Sources: Benefits:
Soluble Fiber Fruits (apples,  Slows down the
pears)with peel, time it takes for
banana, berries,oats, food to pass
beans and barley, rye, through the
peas, onions, tomatoes stomach into
and soybeans the small
intestine
(decreases
transit time)
 Slows the
digestion&
 absorption of
carbohydrate-
so prevents
sudden peaks
of blood
glucose post-
prandially
 Traps fatty
substances thus
lowers their
absorption
 Reduces
cholesterol
absorption by
binding to it in
the gut
 Supports the
gut flora
needed to help
maintain a
healthy gut
 Is digested by
intestinal
bacteria to
produce Short
chain fatty
acids (SCFAs)
Insoluble Fiber Fibrous structures of  Acts as bulking
fruits, vegetables, and agent- prevents
grains that are constipation
indigestible, whole
grains, whole wheat's
bran, nuts, seeds,
green beans, carrots,
celery, cauliflower,
cabbage, cucumber,
radish, turnip and
potatoes
 A bowl of salad prior to the main meal is a perfect starter. This serves not only
as a source of dietary fibers, micronutrients and antioxidants, but also helps to
lower the intake of food by attaining satiety.
In addition, at least one snack time can consist of sprouted seeds and lentils or
roasted pulses; and unhealthy snacking (fried food) better be avoided. A mix of
different legumes and cereals can be sprouted. Sprouts are rich source of fibers,
Vitamins (esply Vitamin A, B complex, C& E), chelated (and hence better
bioavailable) minerals & better bioavailable proteins.
Fats
In the past, fats have been accused far beyond their actual role in pathogenesis
of diabetes and related comorbidities. Recent studies resulted in their acquittal,
even as the beneficial effects of unsaturated fats came to the forefront. Thus, it
is recommended that fat content should be modified such that oils should
replace saturated fats (ghee and hydrogenated fats e.g. Dalda).
Of the 30- 35% of the caloric requirement being met by fats, less than 7%
should be met by saturated fats, 10% by oils rich in Poly-unsaturated fats while
20- 30% by Mono-unsaturated fat sources.

In nature most of the oils are rich in Omega 6 PUFA content, usually lacking in
Omega 3 PUFA and MUFA. As there does not exist an ideal oil in nature, one
must judiciously select a mix of oils to derive appropriate amounts of all the
essential fatty acids.
This calls for a special motivation and an extra effort to deliberately switch to
different oils, giving an additional preference to MUFA rich and Omega 3 PUFA
rich oils.

Trans- fats need to be fully avoided. These are the worst of all fats, as they lower
the ‘good’ HDL cholesterol and raise the ‘bad’ LDL cholesterol, thus increasing
the risk of heart diseases. Trans fats are commercially prepared by adding
hydrogen to vegetable oil through a process called partial hydrogenation,
which makes the oil less likely to spoil. Using trans fats in the manufacturing of
foods helps foods stay fresh longer, have a longer shelf life and have a less
greasy feel. But trans fats are not metabolized in the body and are directly
deposited. They hinder the normal functioning at the cellular level and are
known to be associated with cardiovascular diseases. Hence these days foods
labeled as ‘having Zero- trans fats’ are being marketed.
 Heating and re- heating the oils for deep-frying also convert the fats into trans-
fats, which are difficult to digest and thus are harmful for the body. Thus, it is
advised to either use saturated fats such as coconut oil or butter to fry, as these
contain medium and short fatty acids which are easily utilized by the body and
do not get converted to the dangerous trans- fats; or one should fry in fresh oils
every time and discard the oil instead of re- using it for cooking.

As such in nature, an ideal source of fat is not found. We thus, need to have a mix of
oils for getting adequate proportions of PUFA: MUFA and of Omega 3: Omega 6
components of fats. It is hence advised to use different cooking oils to prepare
different meals in a day.
In general, PUFA consists of Omega-3 and Omega-6 fatty acids. It is advised that Oils
rich in omega-3 fatty acids should be preferred over those rich in omega-6. Some
oils are provided in the below table:

Oil Saturated MUFA PUFA PUFA Omega6 Prominent Remark Approxim

fatty acid ate Cost
fatty Omega Omega :Omega
Rs/lt
acids(SFA) 6 3 3 Ratio

Must 08 70 12 10 6:5 MUFA Has 130

ard Erucic
acid*

Olive 14 75 10 1 10:1 MUFA Has low 800- 1500

smoke
index**

Flax Omega-3 Rich

09 19 14 58 1:4
seed source
of plant
Omega
3

Can 08 54 30 7 4:1 MUFA 250- 600

ola
Grou 24 50 25 0.5 50:1 MUFA 150- 190
nd
nut

Rice 22 41 35 1.5 23:1 MUFA + 120- 140

bran PUFA

Soyb 15 27 53 5 10:1 PUFA 100- 120

ean

Coco 92.1% 6.2% 1 0.6 5:3 Lauric Lauric

nut acid (a acid is
oil Medium similar
chain to that
fatty found
acids) in
mother
’s milk

Sun 13 27 60 0.5 120:1 PUFA 120- 180

flowe
r

Saffl 6 14 75 0 Omega-6 120- 140

ower
oil

Palm 45 44 10 0.5 20:1 SFA+MU 90- 100

FA

*The human health concern with Euricic acid arises from two findings: there is an association between
dietary erucic acid and myocardial lipidosis. Myocardial lipidosis (accumulation of fat droplets in
myocardial fibers) is reported to reduce the contractile force of heart muscle. The occurrence of
myocardial lipidosis can be explained by the effect that erucic acid has on the mitochondrial β–oxidation
system.
Secondly, studies have also demonstrated an association between dietary erucic acid and heart lesions in
rats. It has also been reported as carcinogenic in the rats.

**As olive oil has a low smoke index (360oF), it should not be used for cooking, but 1 teaspoon of Olive
oil can be added to salad, curd or Raita on a daily basis for adequate consumption. Smoke index or smoke
point is the temperature at which an oil or fat gives off smoke. Smoking is an indicator that the fats have
turned rancid and have decomposed, thus the beneficial effects of the oil has been lost. Therefore most of
the Chefs now prefer olive oil for dressing the salads but not for cooking the meal
**Other oils like groundnut, mustard, coconut and soybean oil have high smoke index and thus are
suitable for cooking and frying purpose
Addition of small amounts of MUFA rich oils like olive oil can correct the imbalance
A daily intake of a teaspoon of flax seeds and 5-10 nuts, like almonds and walnuts
should be introduced in the patient’s diet. Dry fruits are a good source of MUFA
and hence should be included as part of daily diet.

These days, many oils in the market claim to contain additional benefits of
antioxidants, attracting the health- conscious consumers. Oils inherently contain
certain antioxidants essential to fight the harmful free radicals released in
metabolic stress
Antioxidants

Mustard Tocopherol

Sunflower Tocopherol

Safflower Tocopherol

Soybean Tocopherol

Ground nut Tocopherol

Rice bran Tocopherol,

Oryzenol,
Tocotrienol

Antioxidants

Metabolic reactions in the body produce a variety of free radicals, which, the
antioxidants combat. In nature a variety of antioxidants are available. An
adequate diet consisting of variety of fruits& vegetables provides sufficient
amount of antioxidants. But Diabetes is a state of constant metabolic stress,
under which the body is at a greater exposure to these free radicals. An
uncontrolled blood glucose level is the main culprit in generating more oxidants.
In the past, it has been over emphasized to supplement the diet with
commercially available antioxidants, but multiple studies have proven that
 antioxidant supplements being provided over the counter or on prescription
play no beneficial role in the management of diabetes.
Thus it is suggested that more emphasis should be laid on including a variety of
fruits and vegetables and on a good glycemic control than on the supplements
available in the market.

Proteins

Protein content should be derived mostly from plants (Legumes, cereals& nuts)
and white meat (especially fishes, chicken breast piece). Red meat sources like
mutton, beef and pork should be completely avoided. Chicken leg pieces,
earlier placed as white meat are now considered dark meat, and it is advised
to better replace them with white meat sources like fishes

Proteins take several hours to get converted into glucose (via gluconeogenesis)
and hence maintain a slow and steady rise in postprandial glucose level.

Patients with nephropathy require a special attention and their protein content must
be lowered according to the extent of kidney damage.

The dietary modifications will eventually reduce the Insulin Resistance and hence, in
conclusion, the clinician must ensure a regular monitoring of the blood sugar levels,
while the patient complies the recommended diet, because the doses of OHAs and
insulin may need to be tittered and revised from time to time, to avoid hypoglycemic
episodes. Caloric value of some of the common food items is given below to help the
clinicians to explain it to the patients.

Reference:

1. Clinical Practice Guidelines Nutrition Therapy Canadian Diabetes Association

Clinical Practice Guidelines Expert Committee
2. Dietary Guidelines for Indians- A Manual: National Institute of Nutrition
3. Erucic acid in food: a toxicological review and risk assessment: technical report series no. 21 food
standards Australia New Zealand
4. Textbook of Preventive and Social Medicine: K Park