Slide 1

Nutrition in Diabetes Lecture

Ericka Ann Lawson, Ph.D.
Visiting Professor
elawson@rossu.edu

Reading pp 515-519 and

Images from: Meisenberg, Gerhard, PhD and William Simmons, PhD. Principles of
Medical Biochemistry, 4th Edition. Elsevier (HS-US), 2017. [Bookshelf Online].
OpenStax, Anatomy & Physiology. OpenStax CNX. Mar 1, 2018
http://cnx.org/contents/14fb4ad7-39a1-4eee-ab6e-3ef2482e3e22@8.119
Slide 2

Learning Objectives
1) Discuss signs, symptoms and management of hypoglycemia in diabetes.
2) Discuss the glycemic index of foods.
3) Explain the effects of alcohol intake in diabetes.
4) Describe the practical approaches in the management of Diabetes.
5) Emphasize the dietary restrictions necessary in the control of blood glucose, levels.
6) Emphasize the team approach to patient care.
7) Explain the role of exercise in controlling blood glucose levels, and in the prevention
of some of the complications of diabetes.
8) Discuss the role of insulin in relation to food intake.
9) Emphasize the treatment goals for obese, type 2 and insulin-dependent diabetics.
10) Discuss gestational diabetes and its effects on pregnancy outcome.
11) Explain the dietary management of pregnant diabetics.
12) Explain the reason for appropriate preventative action during illness or infection.
13) Stress the role of nutritional assessment and patient education in the management of
diabetes, hypertension and heart disease.
Slide 3

The Diabetes Epidemic

Estimated 45% increase in Diabetes incidence between 2017 to 2045
425 million patients world wide in 2017
46 million patients (12% of population) in North America in 2017
Slide 4
Slide 5

Diabetes types
• Remember that:
• Type 1 diabetes is a disease of reduced insulin secretion
• Autoimmune disease with loss of Islet of Langerhans beta cells
• Mechanism of onset is not well understood but genetics and environment seem to be
important
• Type 2 diabetes is a disease of reduced insulin response
• Insulin insensitivity can be due to low numbers of receptors OR,
• More commonly, the tissue does not respond to the insulin in the ‘normal’ fashion
• Alterations in the pathways that allow for mobilization of the GLUT4 cause increase
blood glucose
• GOAL – use dietary, behavioral, monitoring and medicinal interventions to
keep Blood Glucose (BG) between 80-140 mg/dL and Hb A1c <6.5%
Slide 6

Hyperglycemia management
• Symptoms of hyperglycemia include:
• Increased thirst
• Weight loss (mostly type 1)
• Increased urination
• Headaches
• Blurred vision
• Nausea and vomiting
• Fatigue
• Sweet, fruity smelling breath (ketone breath)
• AND a blood sugar greater than 180mg/dL
• Management requires minimization of glucose concentration spikes and
maintaining a moderate glucose level all the time.

1) Condition in which most people feel the effects and symptoms of low blood sugar when
blood glucose levels are lower than 50 mg/dL.
2) Symptoms occur for the following reasons:
a) Eating less carbohydrates than normal
b) Meal with too much carbohydrate
c) Too little Insulin
d) Too little exercise
e) Illness or medication which interferes with insulin response
Slide 7

Hypoglycemia management
• Symptoms are:
• Pale
• Fatigue
• Shakiness
• Irregular heart rhythm
• Anxiety
• Irritability
• Hunger
• Tingling sensation around the mouth
• Crying out in sleep
• Confusion with or without abnormal behavior and difficulty in routine tasks
• Blurred vision
• Seizures
• Loss of consciousness
• Management requires maximizing of glucose concentration between meals
(snacks) and maintaining a moderate glucose level all the time.

1) Condition in which most people feel the effects and symptoms of low blood sugar when
blood glucose levels are lower than 50 mg/dL.
2) Symptoms occur for the following reasons:
a) Skipped Meal
b) Too much Insulin
c) Too much Exercise
d) Illness which interferes with food intake
e) Alcohol on an empty stomach
f) Eating less carbohydrates than normal
3) Guidelines are as follows:
a) Glucose is the preferred treatment
b) 15g-20g glucose is given initially and the response should be seen in 10-20 mins
c) Re-evaluate in 60 mins and give additional treatment if necessary
Slide 8

Practical approaches to diet

• Plate method http://www.diabetes.org/food-and-fitness/food/planning-meals/create-your-plate/
• ½ plate of green, non-starchy vegetable
• ¼ plate of protein
• ¼ plate of grains and starchy foods
• A serving of fruit or dairy
• Glass of water or unsweetened tea or coffee
• Glycemic index method https://universityhealthnews.com/daily/nutrition/glycemic-index-chart/ or
https://www.health.harvard.edu/diseases-and-conditions/glycemic-index-and-glycemic-load-for-100-foods
• Foods are listed with their glycemic index
• Food is selected keeping the glycemic index constant
• Substitution method http://www.heart.org/HEARTORG/HealthyLiving/HealthyEating/HealthyCooking/Smart-
Substitutions_UCM_302052_Article.jsp#.WqgdmOjwaUk
• Uses a substitution list to select “choices”
• Substitution lists have categories with similar effects on blood glucose and similar nutrition
• Developed in 1950s
• Managed carbohydrate method https://www.niddk.nih.gov/health-information/diabetes/overview/diet-eating-physical-
activity/carbohydrate-counting and https://ndb.nal.usda.gov/ndb/
• Eat the same amount of carbohydrates each day
• Read food labels to manage food portions and carbohydrate calories

1) Evaluation of Effectiveness of Diabetic Diet

2) Consistently monitored by testing the following:
a) HBAIC -4.4% - 6.5% good control
b) Blood Lipids< L.DL 100mg/dL H.D.L > 40mg/dL Triglycerides < 150mg/dL
c) Blood Pressure Below: 135/88 mmHg
d) Renal Function
e) Body Weight
3) Reasons for out-of-target blood glucose results, apart from food intake, is stress, infection,
changes in exercise habits, and incorrect medication.
Slide 9

Glycemic Index
• Relative effect of a food on Blood Glucose
• 100 is equal to eating the same amount of glucose
• Can also be determined relative to white bread
• White bread = 100
• makes glucose =140
• More variable since there are many types of white bread, so no single standard bread
• Varies depending on preparation, processing and ripeness of food tested
• Calculated on the response of 10 human subjects
• Particularly useful for those patients with low insulin production
(Type 1 and some Type 2)
• Glycemic index in diabetic patients slightly higher than in non-diabetic
Slide 10

PORTION SIZE
is important
Many patients do not
understand portion sizes;
therefore, they must receive
education on sizes too

FREQUENCY
of meals is
important
BG will remain more stable
with small frequent meals.

1) Give suggested Amounts of Carbohydrate per meal. Ex:

a) Starches and Cereal .. 14-18gms Cho portions
b) Legumes…14-15gms Cho portions
c) Fruit…10-12gms portion
d) Yellow Vegetable... 7-9gms Cho portion
2) Exchange Food System this introduces variety and versatility to the diet.
a) Consists of a list showing which foods can be traded in or exchanged for other
foods which contain approximately the same distribution of Carbohydrate.
i) Protein Foods- e.g. -meat, fish, egg, cheese have no effect on blood glucose levels.
ii) Fats- e.g.- oil, butter do not affect blood glucose levels.
3) A list of free foods should be given to the patient e.g.: cabbage,
i) spinach, unsweetened juices and also handy information, e.g.: 1 tsp. honey or sugar
5gm Carbohydrates; 1Tbls. Ketchup is 5gm Carbohydrates
Slide 11

Table A1. Glycemic index (GI) and glycemic load (GL) values determined in subjects with normal glucose tolerance: 2008
Food Number and Item Subjects Reference food Serve Avail. GL3
GI2 GI2
& time period Carbs /serving
Size
(Glucose = 100) (Bread= 100)
(type & number) g g/serve

BAKERY PRODUCTS
Cakes
1 Banana cake, made with sugar 47±8 67 Normal, 8 Bread, 2h 60 29 14
2 Banana cake, made without sugar 55±10 79 Normal, 7 Bread, 2h 60 22 12
3 Carrot cake, prepared with coconut flour 36 52±3 Normal, 10 Bread, 2h 60 23 8
(Philippines)
7 Pound cake 0% (Bimbo S.A de C.V, Mexico) 38±5 54 Normal, 12 Glucose, 2h 60 25 9
13 Doughnut, wheat dough, deep-fried (China) 75±7 107 Normal, 8 Glucose, 2h 50 20 15
Muffins
14 Apple muffin, made with rolled oats and sugar 44±6 63 Normal, 8 Bread, 2h 60 29 13
15 Apple muffin, made rolled oats and without sugar 48±10 69 Normal, 8 Bread, 2h 60 19 9
16 Apple Blueberry muffin (Sara Lee Bakery, 49±4 70 Normal, 9 Glucose, 2h 60 25 12
Australia)
18 Apricot, coconut and honey muffin (Australia) 60±4 86±6 Normal, 9 Bread, 2h 50 26 16
19 Banana, oat and honey muffin (Australia) 65±11 93±16 Normal, 10 Bread, 2h 50 26 17
20 Blueberry muffin (Sara Lee Bakery, Australia) 50±3 72 Normal, 10 Glucose, 2h 60 31 15
25 Double chocolate muffin (Sara Lee Bakery, 46±4 66 Normal, 10 Glucose, 2h 60 34 16
Australia)
26 Muffin, plain, made from wheat flour (Spain) 46±8 66±11 Normal, 14 Bread, 2h 50 23 11
27 Muffin, reduced-fat, low-calorie, made from 37±3 53±5 Normal, 14 Bread, 2h 50 25 9
high-amylose corn starch and maltitol (Spain)
35 Pancakes, prepared with coconut flour 46 65±3 Normal, 10 Bread, 2h 80 22 10
(Philippines)
Atkinson FS, Foster-Powell K, Brand-Miller JC. International Tables of Glycemic Index and Glycemic Load Values: 2008. Diab Care 2008; 31(12).
Slide 12

Table A2. Glycemic index (GI) and glycemic load (GL) values determined in subjects with impaired glucose tolerance, small subject numbers or values showing wide variability: 2008

Food Number and Item Subjects Reference food Serve Avail. GL3
GI2 GI2 type & number) & time period Carbs /serving
Size
(Glucose = 100) (Bread= 100)
g g/serve
BAKERY PRODUCTS
Cakes
1880 Angel food cake (Loblaw's, Toronto, Canada) 67 95±7 Type 1 & 2, 9 Bread, 3h 50 29 19
1881 Carrot cake, prepared with coconut flour (Philippines) 39 55±4 Type 2, 10 Bread, 3h 60 23 9
1882 Pound cake (Sara Lee Canada, Bramalea, Canada) 54 77±8 Type 1 & 2, 10 Bread, 3h 53 28 15
1883 Sponge cake, plain (Canada) 46±6 66 Normal, 5 Glucose, 2h 63 36 17
1884 Croissant (Food City, Toronto, Canada) 67 96±6 Type 1 & 2, 13 Bread, 3h 57 26 17
1885 Crumpet (Dempster's Corporate Foods Ltd., 69 98±4 Type 1 & 2, 13 Bread, 3h 50 19 13
Etobicoke, Canada)
1886 Doughnut, cake type (Loblaw's, Canada) 76 108±10 Type 1 & 2, 10 Bread, 3h 47 23 17
1887 Flan cake (Weston's Bakery, Toronto, Canada) 65 93±6 Type 1 & 2, 10 Bread, 3h 70 48 31
Muffins
1888 Blueberry muffin (Culinar Inc., Canada) 59 84±8 Type 1 & 2, 10 Bread, 3h 57 29 17
1889 Bran muffin (Culinar Inc., Grandma Martin's Muffins, 60 85±8 Type 1 & 2, 14 Bread, 2h 57 24 14
Aurora, Canada)
1890 Carrot muffin (Culinar Inc., Canada) 62 88±12 Type 1 & 2, 11 Bread, 3h 57 32 20
1891 Corn muffin, low-amylose4 102 146 Type 2, 9 Glucose, 3h 57 29 30
1892 Corn muffin, high-amylose4 49 70 Type 2, 9 Glucose, 3h 57 29 14
1893 Oatmeal, muffin, made from mix (Quaker Oats Co. 69 98±15 Type 1 & 2, 9 Bread, 3h 50 35 24
1894 Pancakes, prepared with coconut flour (Philippines) 51 72±6 Type 2, 10 Bread, 3h 80 22 11

Atkinson FS, Foster-Powell K, Brand-Miller JC. International Tables of Glycemic Index and Glycemic Load Values: 2008. Diab Care 2008; 31(12).
Slide 13

Dietary restrictions
• Reduce consumption of foods that raise blood sugar quickly
• Increase regularity into eating times
• Most diabetics benefit from a 4 meals/day routine to keep blood sugar more
constant; some patients use frequent small meals
• Long periods between meals causes hypoglycemia and increases overeating at the
next meal.
• Reduce sodium intake to 2,300mg/day (1,500 mg/day if hypertension
present)
• Alcohol consumption (♂ ≤2 drinks /day; ♀ ≤1 drink /day)
• Reduce fats that lead to high atherosclerosis and elevated LDL or
cholesterol
• Saturated fats – common in beef, pork and dairy
• Trans fats – common in processed foods and fried foods
• Cholesterol – common in dairy, animal fats, organ meats and egg yolks (<20mg/day)
Slide 14

Alcohol and Diabetes

• Alcohol blocks the production of glucose by the liver increasing
hypoglycemia
• Eat before drinking to keep blood glucose steady
• Skipping a meal then drinking increases risk of hypoglycemic event.
• Patient should wear a “MED-ALERT” to help medical professional
differentiate between drunk and hypoglycemia
• May induce a hypoglycemic event for up to 24 hours after
consumption
• Alters the effectiveness and dosing of medication
Slide 15

Team approach to care

• In the US, Medicare supports the nutritional counselling of patients with diabetes
(medical nutrition therapy)
• BG monitoring data gathered and scanned by physician for adjustments in
medication
• Patient education and compliance is essential
• Diabetes educators - tailor patient’s understanding of lifestyles and diet to better
control BG
• Dietitians – tailor patient understand and preferences for BG control
• Patient and family education for identification of signs and symptoms of both
hyperglycemia and hypoglycemia as well as medication use and testing.
• Physical or occupational therapists provide activity programs that meet weight
and blood glucose goals

1) It is imperative that the full team understand and speak in a way the patient understands
and that take into consideration cultural and socioeconomic issues
2) “one size fits all” is the worst approach. Treat each patient as unique.
Slide 16

Treatment goals for obesity, metabolic

syndrome and diabetes
• Loss of 10 pound improves insulin sensitivity in most overweight or
obese patients
• Steady/constant Blood glucose below 180 mg/dL
• HbA1c – below 7% or 154 mg/dL- hemoglobin is slowly glycosylated
and is a indirect measure of average (2-3 months) Blood glucose
levels under 6.5%
• Management of comorbidities
• Cardiovascular Disease
• Kidney disease
• Liver Disease
• Neuropathy

1) Ensure attainment of normal Blood Glucose, Blood Pressure and Blood Lipid Levels
(monitoring)
2) Achieve moderate weight loss; this Improves ability of receptor sites to receive Insulin.
Moderate weight loss of 10-20lbs is sufficient for improving glycemic control, intake of
about 500 less cals per day is effective.
3) Reduce total fats especially saturated fats (20-25% of cals from fat)
4) Ensure proper meal spacing. Use smaller meals and snacks at 4 hourly intervals- This will
prevent exaggerated post – meal hyperglycemia.
5) Moderate Regular Exercise
6) Encourage Behavior Change
7) Support mechanism to prevent relapse
8) Maintenance Program
9) Keep mealtimes constant from day to day
Slide 17

Exercise
• Goal of 150 minutes of moderate aerobic exercise per week
• 30minutes per day 5 days a week
• 10 minutes in morning, 10 minutes at lunch and 10 minutes in the evening
• Must monitor BG before during and after exercise
• If using an Insulin pump, adjust basal level
• If BG < 100mg/dL snack before exercise
• If BG is downward trending before exercise use snack or rehydrate with juice or glucose tabs
• Must maintain proper hydration
• Helps maintain weight
• May improve insulin sensitivity in some Type 2
• Reduces risks of comorbidities like CVD
• DO NOT exercise if blood or urine ketones positive

1) Exercise causes increased Insulin sensitivity in Type II Diabetes which results in

increased peripheral use of Glucose
a) Exercise decreases the effect of the counter- regulatory hormones, which in turn,
reduces the Hepatic Glucose output and results in improved Glucose control.
b) Exercise aids in weight management, which is beneficial to glycemic control
c) Exercise lowers Blood Pressure
d) Exercise improves the circulation in the extremities
e) Exercise reduces stress and gives a sense of well being
f) Benefits of Physical Activity is greatest in the early progression of the disease and
encouraged for all persons with diabetes.
2) Overall, persons living with diabetes should:
a) Detailed medical evaluation before embarking on an exercise regime.
b) Engage in aerobic physical activity daily
c) Careful attention to hydration status during and after exercise.
Slide 18

Insulin administration relative to food

• Goal is to time insulin and meals to reduce spikes of BG
• Type 1 diabetics require insulin
• Type 2 may use insulin, sulfonylureas or other medications to
stimulated insulin secretion
• Minimize the peaks and valleys of blood glucose
• Form of insulin or oral mediations used varies timing of administration
• Pumps allow faster control

1) Type 1
a) Consistency in quantity of food intake to match amount of Insulin
b) Consistency in timing of meals to match onset and duration of Insulin action
c) Snacks are important particularly at peak action of Insulin (to prevent
Hypoglycemic events) and before and after exercise
d) Frequent self-motoring of Blood Glucose if patient is on intensive Insulin Therapy.
3-4 Doses per Day.
2) Type 2
a) Similar to Type 1
b) Exercise more important
c) Self-monitoring is highly recommended
Slide 19

Pregnancy and diabetes

• 2 types of gestational diabetes
• Both treated with diet and exercise
• Type A2 may require insulin and medicaiton
• Management of BG required for maternal and fetal health
• Babies born after high average BG during pregnancy more likely to develop Type 2
and be overweight
• Maternal problems:
• Pre-eclampsia
• Depression
• Caesarean section
• Neonatal problems:
• Overweight/too large
• Hypoglycemic after birth with elevated insulin
• jaundice
• stillbirths
• Breast feeding as soon as possible after birth recommended

1) Clients who have diabetes and become pregnant will require re-assessment and
modification in their management
2) The aim is for the client to achieve appropriate weight gain or control measures
and match age needs, thus contributing to a healthy outcome.
a) Recommended total weight gain is 11.8 kgs (26 pounds)
b) (9-1.8kgs) 1-2lbs should be gained during the 1st trimester
c) not more than 2.2lbs every 2 weeks thereafter
3) It is important to monitor blood glucose levels, urine ketones, appetite and weight
and adjust the meal plan, throughout the pregnancy to achieve desired results.
4) Ketonuria indicates starvation ketosis and should be prevented
Slide 20

Prevention of hypo/hyperglycemic issues

during illness and infection
• Acute illnesses alter the rate of glucose use and therefore alter BG
• Mucous membranes prone to yeast and bacterial infection and colonization
• Skin infections increase as well
• Increase BG monitoring to prevent high/low spikes
• Ensure good hydration to lessen ketoacidosis effects
• High BG weaken immune response
• Increased frequency and risk of acute infections
• Chronic illnesses
• Closer monitoring of BG required
• Some medications interfere with diet, exercise and BG regulation
• Neuropathy worsens many comorbidities
• Microvascular changes affect both DM and comorbidities
• Physician must maximize all comorbidities

1) Insulin Medication should NOT be stopped. Patient should be referred for assessment by
medical team to prevent ketoacidosis.
Slide 21

Nutritional assessment and patient education

• Tools exist for assessing nutritional and lifestyle history
• See example on eCollege and https://www.nestlenutrition-
institute.org/resources/nutrition-tools
• Screening forms
• Dietary intake forms
• 24hr recall form
• Food frequency
• Food records/diary
• Dietary history questionnaires

1) Step 1 (Very Important):

a) Evaluate of the status of the individual.
b) Important tool for identifying existing and potential problems, and recognizing clients
needing more comprehensive screening.
2) The assessment process is the systematic process of collecting objective information
about the client in his/her environment and the support system.
3) Results of assessment gives some insight into some of the challenges the client may face
and resources that are available to cope with them.
4) Assessment should include:
a) A review of historical data (Health history, Drug History, etc.)
b) Anthropometric, Biochemical, Clinical and Dietary data which should include 24-hour
recall, food frequency and shopping list.
c) Determination of Activity level / Exercise.
d) Assessment of client’s ability and readiness to participate in Care Plan.
e) Assessment of client’s support network. Home/Community.
f) Interpretation of Data.
g) Use of data to provide appropriate care.
Slide 22
Lastly
• Make sure patient is actively involved in their care
• Required for initial consistency and compliance
• Needed to keep motivation high
• Allows fine tuning of care
• Allows corrections of misconceptions or myths
• Helps keep compliance high
• Keep support network (family and community) involved
• Keeps patient motivated
• Family/friends may contribute observations that are unique
• Allows fine tuning of care
• Keep documentation of all initial and follow up evaluation and
discussions