After learning epidemiology types of diabetes, diagnostic criteria, pathogenesis and complications of diabetes you should learn management of diabetes also.Diabetic management revolves around the concept of patient empowerment. Through education, regular consultation, and encouragement and feedback it is possible to make the patient responsible for his1 her diabetic control. The formation of special diabetic clinics which involve a multi-disciplinary team, have been advocated to achieve comprehensive care. The members of an ideal team include nurse-practitioner, dietitician, chiropodist (foot-care specialist), physiotherapist, health educationist, social worker, ophthaltnologist, and a family doctor. However, in practice the same can be achieved by the doctor and a nursepractitioner who is specially trained in diabetic care.
The main tools for metabolic control of diabetes involves the use of diet modification,oral hypoglycenlic agents, and insulin.
Dietary Principles
A proper diet is the cornerstone of diabetic management, and neglect of adherence to methods.this basic principle will negate the effect of all ph~ul~~acological.It is necessary to have a concept of
1 ) total calorie requirement for an individual, and,
2) the proportion of macro-nutrients (carbohydrates, proteins, Fdts), suitable for a diabetic.
Total Calorie Requirement
The calorie requirement for a diabetic is estimated such that it helps to achieve the ideal body weight (IBW). The IBW is calculated by several methods, one of which is Brocas' formula:
The IBW Calorie requireineilts are calculated as follows:
Basal calolies (needed for metabolic functions) = is 22 Kcall kg ideal body weight.
To the basal calories must be added additional calories depending on the activity level which is classified as sedentary, moderate and heavy physical activity.Sedentzuy activity: Add 10 per cent of basal calories.Moderate activity (e.g,, A housewife who does all the housework): Add 20 per cent of basal calories.Heavy pllysical manual labour (e.g., A construction worker): Add 40 per cent of basal calories.Thus for a 60 kg person doing heavy manual work the calculated calorie intake would be :
Basal calories = 22 x 60 = 1320 calories
Activity calories = (40 + 100) x 1320 = 548 calories
Total calories = 1320 + 548 = 1848 calories
In general most average weight patients (60 to 70 kg), doing moderate activity require 1500 to 1600 calorie diets.
Meal Plan
Having estimated the total calorie requirement, we now need to decide how much of fats, casbohydrates, proteins, fibre and micro-nutrients are required.The accepted proportion of macro-nutrients for a diabetic is as follows:Cnrbohydrates: 55-60 per cent of total calories. Complex carbohydrates are preferred because the absor p tion is delayed and thus the post-prandial elevation of glucose is less than if refined carbohydrates were ingested. For example chapatti is preferable to bread because wheat flour is less refined. There has been an attempt to classify foods according to their ability to raise blood glucose levels by comparing weight for weight
carbohydrate content. This has been termed the glycernic index. Foods with high glycemic index should be avoided. However, there is no universal acceptance of this idea, but it remains a useful concept.
Proteins: 10-20 per cent or 0.85 girdkg body weight. This allowance will need reduction when renal failure occul-s.
Fats: < 30 per cent. Cholesterol component must not exceed 300 mgs/ day. Saturated fats should be low, and mono-and polyunsaturated fats of higher composition.
Fibre: High fibre diet helps to reduce blood lipids and glucose values. About 30 to 40 grns of fibre per day is ideal.
Swetcling Agents
Sweetening agents altel-native to sucrose are available. Those that do not contain caloiies are saccharin, aspartame and acesulfame K. Saccha in has a bitter after taste.Aspartame cilnnot be heated. Acesulfame can withstand heating.Sweetening agents which contain calories (4calIgm) are Sructose, sorbitol, xylitol.Fructose is sweeter than sucrose and hence the quantity required is less. The other sugars are absorbed more slowly and therefore cause less rise in blood glucose,however, they can cause osmotic diarrhoea if ingested in large quantities.
Meal PIallnil~g for a Patient
The steps involved in actually advising a patient on the acceptable levels and types of rood therefore requires an in depth understanding of the coinposition of foods. In practice l~owever, ready-made diets for various levels of calories can be prepared, and simple quick advice can be given and reinforced at each consultation. It is however preferable to have a dietician who can do the initial assessment and diet prescription.
Food Exchanges
The concept of food exchanges is to help to add variety to the diet, and give the patilnt some autonoiny in choosing different foods. For example if the staple food is chappatis, the equivalent quantity of rice, or bread slice is given r so that these can be substituted when desired (see appendix I ) .
Food Guide Pyramid
Many illiterate palients would find it difficult to read a written meal plan. Hence alternative pictorial lists may need to be given. Another simple pictorial qualitative method of educating patients on a proper diet is the sue of the food guide pysamid,which is reproduced below:
The main tools for metabolic control of diabetes involves the use of diet modification,oral hypoglycenlic agents, and insulin.
Dietary Principles
A proper diet is the cornerstone of diabetic management, and neglect of adherence to methods.this basic principle will negate the effect of all ph~ul~~acological.It is necessary to have a concept of
1 ) total calorie requirement for an individual, and,
2) the proportion of macro-nutrients (carbohydrates, proteins, Fdts), suitable for a diabetic.
Total Calorie Requirement
The calorie requirement for a diabetic is estimated such that it helps to achieve the ideal body weight (IBW). The IBW is calculated by several methods, one of which is Brocas' formula:
The IBW Calorie requireineilts are calculated as follows:
Basal calolies (needed for metabolic functions) = is 22 Kcall kg ideal body weight.
To the basal calories must be added additional calories depending on the activity level which is classified as sedentary, moderate and heavy physical activity.Sedentzuy activity: Add 10 per cent of basal calories.Moderate activity (e.g,, A housewife who does all the housework): Add 20 per cent of basal calories.Heavy pllysical manual labour (e.g., A construction worker): Add 40 per cent of basal calories.Thus for a 60 kg person doing heavy manual work the calculated calorie intake would be :
Basal calories = 22 x 60 = 1320 calories
Activity calories = (40 + 100) x 1320 = 548 calories
Total calories = 1320 + 548 = 1848 calories
In general most average weight patients (60 to 70 kg), doing moderate activity require 1500 to 1600 calorie diets.
Meal Plan
Having estimated the total calorie requirement, we now need to decide how much of fats, casbohydrates, proteins, fibre and micro-nutrients are required.The accepted proportion of macro-nutrients for a diabetic is as follows:Cnrbohydrates: 55-60 per cent of total calories. Complex carbohydrates are preferred because the absor p tion is delayed and thus the post-prandial elevation of glucose is less than if refined carbohydrates were ingested. For example chapatti is preferable to bread because wheat flour is less refined. There has been an attempt to classify foods according to their ability to raise blood glucose levels by comparing weight for weight
carbohydrate content. This has been termed the glycernic index. Foods with high glycemic index should be avoided. However, there is no universal acceptance of this idea, but it remains a useful concept.
Proteins: 10-20 per cent or 0.85 girdkg body weight. This allowance will need reduction when renal failure occul-s.
Fats: < 30 per cent. Cholesterol component must not exceed 300 mgs/ day. Saturated fats should be low, and mono-and polyunsaturated fats of higher composition.
Fibre: High fibre diet helps to reduce blood lipids and glucose values. About 30 to 40 grns of fibre per day is ideal.
Swetcling Agents
Sweetening agents altel-native to sucrose are available. Those that do not contain caloiies are saccharin, aspartame and acesulfame K. Saccha in has a bitter after taste.Aspartame cilnnot be heated. Acesulfame can withstand heating.Sweetening agents which contain calories (4calIgm) are Sructose, sorbitol, xylitol.Fructose is sweeter than sucrose and hence the quantity required is less. The other sugars are absorbed more slowly and therefore cause less rise in blood glucose,however, they can cause osmotic diarrhoea if ingested in large quantities.
Meal PIallnil~g for a Patient
The steps involved in actually advising a patient on the acceptable levels and types of rood therefore requires an in depth understanding of the coinposition of foods. In practice l~owever, ready-made diets for various levels of calories can be prepared, and simple quick advice can be given and reinforced at each consultation. It is however preferable to have a dietician who can do the initial assessment and diet prescription.
Food Exchanges
The concept of food exchanges is to help to add variety to the diet, and give the patilnt some autonoiny in choosing different foods. For example if the staple food is chappatis, the equivalent quantity of rice, or bread slice is given r so that these can be substituted when desired (see appendix I ) .
Food Guide Pyramid
Many illiterate palients would find it difficult to read a written meal plan. Hence alternative pictorial lists may need to be given. Another simple pictorial qualitative method of educating patients on a proper diet is the sue of the food guide pysamid,which is reproduced below:
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| Food Guide Pyramid |
1. Avoid or restrict foodstuffs high in saturated fat and cholesterol.
2. Avoid sweet foods, jams, chocolates, cakes, sweet cream, which increase triglyceride levels.
3. Bake, roast, boil or steam instead of frying food.
4. Do not replace oil and fat with calories in terms of sweets which when taken in excess get converted to triglycerides.
5. It is better to avoid alcohol. Too much alcohol may cause low blood sugar by potentiating the effect of insulin or drugs and blocking glucose production in the liver while adding to calories. It can cause increase in cholesterol and triglycerides.
Artificial sweeteners like aspartame and saccharine tables are available. They are safe and may be used in moderate amounts.
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