This document outlines dietary guidelines for managing diabetes mellitus through medical nutrition therapy. The goals are to provide adequate nutrition for normal growth and development, prevent hypo- and hyperglycemia, and promote lifestyle changes to improve metabolic control. A balanced meal plan calls for 50-60% of calories from carbohydrates, 20-30% from fat, and 10-15% from protein. Meals should be spaced regularly and consistently with flexible timing. Exercise and self-monitoring of blood glucose are also integrated into treatment. Hypoglycemia is managed through consumption of simple sugars to quickly raise blood sugar levels.

1. Dietary management in Diabetes
Mellitus- Medical nutrition therapy
Dr . Abhijeet Deshmukh

2. Goals
• Provision of adequate nutrition & balanced
calories for
– Normal growth & development.
– Prevention of Hypo/ Hyperglycemia.
• Change in eating behaviors & promote
physical activity to
– Reduce insulin resistance & improve metabolic
control.

3. • Biochemical goals
– FBS< 115 mg/dl,
– PPBS < 126mg/dl ,
– Sr Cholesterol < 200
– LDL < 130
– HDL > 50 TGs < 160
– Glycated Hb -6-8 gm%

4. Meal Plan
• High fibers , low fat diet with adequate calories &
proteins.
• Carbohydrates- 50-60%, Fat- 20-30%,
Proteins 10-15%
• According to familiy’s religious beliefs & eating
habits.
• Insulin therapy & Self blood glucose monitoring
(SBGM) integrated.
• Avoid fasting & feasting.

5. • Individualised flexible nutrition plan to facilitate
compliance.
• Regular meal timing, consistent quantity,
relatively fixed composition,
• Thorough review of dietary intake annually or
earlier if
– Unexplained growth failure,
– Unexplained Hyper/ Hypoglycemia,
– Excessive wt gain/ loss,
– HTN, Hyperlipidemia, Nephropathy, Elevated Hb A1 C

6. Nutritional Intervention
• Offering structure for meal planning-
1. Menu based
2. Exchange list based
3.Carbohydrate counting (Preferred)
• It includes 4 steps-
1. Assessment
2. Goal setting
3. Intervention
4. Evaluation

7. 1. Assessment
– 24 Hr recall food history
– Carbohydrate intake per meals & snacks
– Other factors : Timing of meals, Timing & Amount
of exercise, Frequency & Rx of hypoglycemia.
– Assess readiness of patient for change in diet.

8. 2. Goal setting
– Diet & lifestyle changes
– Metabolic outcomes
3.Intervention
Level 1
– Practice identifying carbohydrate foods
– Recognize 10-15 gm carbohydrate portion of
foods.
– Plan sample meal

9. • Level 2
– Blood glucose reading
– Maintain physical activity log
• Level 3
– Calculate carbohydrate: Insulin ratio
i.e. Total gm of carbo. Per meal: Units of rapid acting
insulin analogue taken before meal.

10. 4. Evaluation
– Access effect of intervention

11. Calories distributed with
NPH (Lente) regimen
• Breakfast 20%
• Lunch 20%
• Dinner 30%
• Snacks
– Midmorning : 10%
– Mid afternoon : 10%
– Evening : 10%

12. • Carbohydrates
– 55 % of total calorie intake
– Avoid rapidly absorbed mono/
disaccharides(Simple) & refined sugars like
glucose, sugar, honey etc (30%)
– Encourage complex carbohydrates like starch -70%

13. – Wheat is preferred over rice(Acarbose : slow
absorption)
– Tubers restricted
– Minimum daily carbohydrate intake > 130 gm
above 1 yr of age

14. • Exchange system : to ensure fixed energy
intake and avoid monotony
• 1 exchange system: 10 gm of carbohydrate
– ½ slice bread, ½ banana
– 1 glass of milk, 1 glass of curd
– 1 cup thin soup, 1 cup porridge
– 1 tomato/ apple/ orange

15. • Glycemic index:
– Increase in RBS following ingestion of single food
as % of increase following standard food
– Glucose 100%, potato 90%, rice 72%, wheat 65%,
ice cream 43%, apple 40%, soyabean & peanut
20%
– Food items with low glycaemic index are
encouraged
– Not much of significance, affected by multiple
factors

16. Exercise
• ↓ insulin requirement and LDL, ↑ HDL
• Provide extra calories for exercise
– No exercise until RBS < 300 mg%
– No extra calories if RBS 180- 300
– Extra calories if RBS < 180

17. Type of exercise Carbohydrtes to be
given gm/hr of
exercise
Food item
Mild (< 30 min) 10-15 before 1 fruit
Moderate (1 hr) 25Before
10-15 after
½ sandwich+ 1 glass
milk
1 fruit
Severe ( 1-2 hr) 50Before
10-15 after
1 sandwich+ 1 glass
milk
1 fruit

18. • Fruits: when blood sugar is well controlled ½
to 1 fruit at the expense of snacks or after
exercise
• Carbohydrate content:
– < 5%: cabbage, spinach, brinjal, cucumber,
drumsticks, tomato, watermelon
– 5-20%: cauliflower, beat root, peas, ladies finger,
papaya, apple, orange, strawberry, grapes, lime,
mosambi
– > 20%: potato, banana, jack fruit

19. • Fibers:
– 25-35 gm/day
– Unabsorbed plant polysaccharides
– Delays carbohydrate absorption, decreases
hyperglycemia, increases insulin receptors,
decreases insulin requirement
– Pectin, gums- bind to bile salts, increase their
excretion, hence decreases cholesterol
– Ragi, pulses, ground nut, guava- 3-5% of fibers

20. FATS
• 30% of calories
• Saturated fat < 10% calories,
with elevated LDL< 7 %
• PUFA up to 10% of calories
• PUFA/ saturated fat 1.2:1
• Infants and children < 2 yrs , no restriction of
dietary fat
• Avoid animal fat and hydrogenated oil
• Fish and chicken preferred to beef and egg

21. • Turmeric , Bengal gram, onion, garlic-
decreases cholesterol
• If cholesterol is increased rule out
autoimmune hypothyroidism
• Low fat
– Increases insulin binding
– Decreases LDL, VLDL

22. • PROTEIN:
15 % of total calorie intake
if nephropathy 8-10%
microalbuminuria 0.8 gm/kg/d

23. Sweeteners
• Non nutritive:
– Improves palatability without increasing energy intake
– Saccharin, aspartame, accusulfame, neotame, sucralose
– Saccharin may cause hepatic and bladder malignancy
• Nutritive:
• sucrose:
– No adverse effect in usual amounts
– Should not be restricted
– Counted in tally of carbohydrtes
• Fructose:
– May be chanelled into glucose pathway, so avoid

24. • Na - < 3 gm/day
< 2.4 gm/day if HTN
• Vitamins and minerals: as per regular
requirement

25. Hypoglycemia
• Decreased food intake, increased activity
• Goal: rapid normalization of blood sugar
without use of excess food thus avoiding
resultant hyperglycmia

26. • Management:
1. Simple sugar( juice, glucose tablets)
rapidly absorbed, raise blood sugar within 10-15 mins
15 gms = 30 mg/dl
2. Repeat RBS after 15 mins, if < 80
give one exchange( 15 gm)
3. Repeat after 10 mins, if > 80
give 15 gm carbohydrate with protein snack or
planned meal/ snacks within 30-60 mins

27. Thank You