Development of cancer
Characteristics of Cancer
Difference between tumor and cancer
Identification of Cancer Cells
Etiological risk factors in cancer
Metabolic Alterations during Cancer
Clinical Manifestations and Nutritional Problems
Associated with Cancer
• Diagnostic Tests
• Nutritional requirements of cancer patients
Cancer :Key facts
• Cancer is a leading cause of death worldwide, accounting for 7.6
million deaths (around 13% of all deaths) in 2008 .
• Lung, stomach, liver, colon and breast cancer cause the most cancer
deaths each year.
• The most frequent types of cancer differ between men and women.
• About 30% of cancer deaths are due to the five leading behavioral
and dietary risks: high body mass index, low fruit and vegetable
intake, lack of physical activity, tobacco use, alcohol use.
• Tobacco use is the most important risk factor for cancer causing
22% of global cancer deaths and 71% of global lung cancer deaths.
• Cancer causing viral infections such as HBV/HCV and HPV are
responsible for up to 20% of cancer deaths in low- and middleincome countries.
• About 70% of all cancer deaths in 2008 occurred in low- and
• Deaths from cancer worldwide are projected to continue rising,
with an estimated 13.1 million deaths in 2030
There are more than 100 types of cancers; any part of the body can
In 2008, 7.6 million people died of cancer - 13% of all deaths
Worldwide, the 5 most common types of cancer that kill men are (in
order of frequency): lung, stomach, liver, colorectal and oesophagus.
Worldwide, the 5 most common types of cancer that kill women are
(in the order of frequency): breast, lung, stomach, colorectal and
cervical. In many developing countries, cervical cancer is the most
Tobacco use is the single largest preventable cause of cancer in the
world causing 22% of cancer deaths
One fifth of all cancers worldwide are caused by a chronic infection,
for example human papilloma virus (HPV) causes cervical cancer and
hepatitis B virus (HBV) causes liver cancer.
Cancers of major public health relevance such as breast, cervical and
colorectal cancer can be cured if detected early and treated
More than 30% of cancer could be prevented, mainly by not using
tobacco, having a healthy diet, being physically active and moderating
the use of alcohol. In developing countries up to 20% of cancer
deaths could be prevented by immunization against the infection of
HBV and HPV.
Cancer in India
Cancer prevalence in India is estimated to be around 2.5 million,
with over 8,00,000 new cases and 5,50,000 deaths occurring each
year due to this disease
More than 70% of the cases report for diagnostic and treatment
services in the advanced stages of the disease, which has lead to
a poor survival and high mortality rate.
The impact of cancer is far greater than mere numbers. Its
diagnosis causes immense emotional trauma and its treatment, a
major economical burden, especially in a developing country like
Different cancers occur in different states of our country.
Esophageal cancers: Southern states of India like Karnataka
Nadu and also in Maharashtra and Gujarat.
Stomach cancers: Southern India with the highest incidence in
Oral cancers: Kerala (South India)
Pharyngeal cancers: Mumbai (Western India)
Thyroid cancers among women: Kerala
Gall bladder cancer: Northern India, particularly in Delhi and
• Among men, lung, esophagus, stomach, oral and pharyngeal
cancers are more prevalent,
• while in women, cancers of cervix and breast are most
common, followed by those of stomach and esophagus.
• The word 'cancer' comes from the Latin for crab. It
refers to any malignant growth or tumor caused by
abnormal and uncontrolled cell division.
• When a cell is set loose from normal control, it
becomes what is known as transformed.
• Basically, the cell no longer looks like its
neighbours in terms of its shape, size, and its
internal components. This transformed property
is conferred upon all of the daughter cells. That
is, all subsequent cells that arise from that
initially transformed cell will also look different
and grow in an uncontrolled manner.
• This is the transmissible nature of cancer - once
one cell becomes cancerous, all cells that arise
from this abnormal cell also take on this
• Cancer is a tumour or new growth which has a high
growth factor. The new growth may be benign or
• A malignant growth can kill a patient if left
untreated. A malignant tumour can invade the
surrounding tissue and release cells that can be
carried to other parts of the body and set up
metastasis (growth of malignant tissue that spreads
to the surrounding tissues).
• A benign growth is non malignant.
Development of Cancer
• The cancer development is a process involving
initiation, promotion and progression .
• The first step is initiation when the exposure to a
carcinogen allows the carcinogen to enter the cell. This
carcinogen then alters the cellular DNA
• The second step is promotion when there is
enhancement of cancer development and the cell
begins to multiply uncontrolled.
• The third step is known as progression when a tumor
formation takes place. It may spread to other tissues or
• Thus the cells released and carried to other parts of the
body are called as metastasis.
Characteristics of Cancer
The important characteristics of cancer are
excessive cellular multiplication, invasiveness
and autonomy. The active process of invasion
is known as metastasis.
The process of invasion is as follows
• Metastatic cell penetrates the extra cellular matrix that
surrounds the tumor and travels through the tissue
until it reaches a blood vessel or a lymphatic vessel
• It dissolves a portion of the wall and then propels itself
through the circulating blood.
• At distant site, the tumor cell again re-attaches to
blood vessel wall and repeats the process until it
settles down and begins to form a new tumor.
• Tumor cells gain growth autonomy by either activation
of growth promoting antigens or loss of growth
inhibitory cancer suppressor genes.
• The cancer suppressor genes are called antioncogenes.
Difference between tumor
• Tumor is a swelling or growth because of an abnormal
growth of tissue. Tumors can either be benign or
• The benign tumor remains highly localized.
• On the other hand, the malignant tumor known as
cancer is characterized by invasiveness and can form
distant colonies elsewhere in the body.
• Cancer cells are very irregular in shape and their
arrangement in tumor tissue is very unruly.
• Cancer is painless if it does not compress the adjacent
organs. Later, it causes pain by invading or pressing the
adjacent vital organs.
Identification of Cancer Cells
• Cancer cells can be distinguished from normal
cells by examining them under a microscope.
• In a specific tissue cancer cells are usually
recognized by the characteristics of rapidly
growing cells, a high nuclear to cytoplasm ratio,
prominent nucleoli, many mitoses and relatively
little specialized structure.
• The presence of invading cells in an otherwise
normal tissue section is the most diagnostic
indication of malignancy.
Malignant tumors can be classified as:
these tumors arise from the epithelial lining (the squamous cells)
e.g. skin, tongue, breast, stomach, large intestine (the latter three
arise from the glandular tissues).
these arise from the connective tissue e.g. bone, cartilage and fat.
arise from pigmented layers of skin e.g. pigmented moles.
• Gliomas :
these arise from the central nervous system e.g. brain and spinal
• Reticulo -endothelial tumors:
these involve the lymphatic system.
the growth arises from a gland e.g. thyroid gland.
ETIOLOGICAL RISK FACTORS IN
Carcinogenic: Dietary Factors
Carcinogenic: Non-dietary Factors
1. Oncogenic viruses
2. Chemical carcinogens
3. Radiant energy
• Stress Factors
• Some cancers are programmed by genes to develop.
Gene mutation is result from one or more regulatory
genes in the cell nucleus. It might be an inherited one
but environmental factors also contribute to its
expression. Person with a family history of cancer
have a greater risk of developing cancers than a
person without such a genetic pre-disposing factor.
Among environmental factors, smoking, water
and air pollution and sun light exposure are
known to cause cancer.
Carcinogenic: Dietary Factors
• Dietary constituents can also be
carcinogenic. But to what extent
diet is one of the contributing
factors to cancer development is
• The incidence of cancers,
especially stomach cancers is high
in parts of the world where people
eat a lot of heavily smoked, pickled
or salt-cured foods that produce
• Alcohol has also been associated
with a high incidence of some
cancers, especially cancers of the
mouth and throat. Beverages such
as beer and scotch may contain
damaging nitrosamines, as well as,
alcohol. Other beverages such as
wine and brandy may contain the
carcinogen urethane, which is
produced during fermentation.
Carcinogenic: Non-dietary Factors
• A large number of agents cause genetic
damage and induce neoplastic transformation
of cells, they fall into the following categories.
1. Oncogenic viruses
2. Chemical carcinogens
3. Radiant energy
Certain viruses that interfere
with the functions of the
regulatory genes have been
identified. These viruses are
called oncogenic viruses.
A large number of DNA and RNA
viruses have been proved to
be oncogenic in animals.
• The three DNA viruses found to cause human cancers are
EBV, HBV and HPV.
• Epstein-Barr virus (EBV): EBV belongs to herpes family. It
causes Burkitt‘s lymphoma. It is a tumor of B-lymphocytes.
In patients with immune disregulation, EBV causes
sustained beta cells proliferation. EBV is found to be closely
associated with nasopharyngeal carcinoma.
• Hepatitis B Virus (HBV) : Hepatitis B virus infection is found
to be closely associated with formation of liver cancer.
• Human Papilloma Virus (HPV) : HPV gives rise to multiple
warts, which are benign squamous papillomas. Some of the
warts undergo malignant transformation. Squamous cell
carcinoma of cervix has been found to be associated with
• All oncogenic RNA viruses are
retroviruses. They are of 2
• acute transforming
retroviruses include type C
viruses and cause rapid
induction of tumors in
animals. They contain viral
• slow transforming
retroviruses are replication
competent and cause
transformation of the cells
Chemicals have been shown to be carcinogenic.
Some are naturally occurring components of
plants and microbial organisms .
Some are synthetic products created by industry.
Chemical carcinogens can be classified into two
general categories based on the ability of
compounds to bind to DNA.
Compounds that bind to DNA are genotoxic,
whereas compounds that are carcinogenic, but have
no evidence of DNA binding are termed epigelzetic.
Some of the major chemical carcinogens :
insecticide and fungicide
Tobacco, smoking, drug abuse are also
known to cause cancers.
• Radiant energy whether in the form of the
ultraviolet rays of sunlight or as ionizing
electromagnetic and particulate radiation
can transform all cell types in vitro and
induce neoplasm in vivo in both human and
• Ultraviolet rays: There is ample evidence
from epidemiological studies that ultra
violet rays derived from the sun induce an
increased incidence of squamous cell
carcinoma, basal cell carcinoma and
melanocarcinoma of the skin.
• Ionizing Radiation: Electromagnetic (Xrays, gamma rays) and particulate (α particles,β - particles, protons, neutrons)
radiations are all carcinogenic.
• Emotions playing a part in
malignancy are not a new idea. But
these relationships are extremely
difficult to measure.
• Clinicians and researchers have
reported that psychic trauma, seems
to carry strong correlations with
cancer. Two important physiological
causes are assured for this
• One is damage to the thymus gland
and the immune system. Second js
the neuroendocrine effects mediated
through the hypothalamus, pituitary
and adrenal cortex.
• Cancer patients have been shown to have glucose
intolerance. This is due to an increased insulin
resistance and also reduced insulin secretion.
• An increased rate of Cori cycling has been reported
to occur in cancer patients.
• In Cori cycle, glucose released by peripheral tissues
is metabolized to lactate, which is then
resynthesized to glucose in the liver.
• This process is energy consuming because 6 ATP are
required for synthesizing of 2 ATP.
• Therefore, if the tumor cells release more lactate,
more energy will be wasted on the resynthesis of
• So, the Cori Cycling could be one of the significant
factors in the development of weight loss.
• Many research reports have stated that the major
portion of weight loss in cancer patients is mainly due
to body fat depletion.
• These include increased lipolytic (break down of fats)
rates caused by decreased food intake, stimulation of
lipolysis due to the stress response to illness and
release of lipolytic factors produced by the tumor itself.
• Loss of body fat occurs when both lipolysis and fatty
acid oxidation are increased.
• The rate of fat oxidation is found to be greater than the
rate of carbohydrate oxidation in cancer patients who
had lost weight significantly.
1. Catabolic (breakdown) rates of muscle protein
increase with advancing stages of disease
leading to weight loss.
2. Decreased plasma branched - chain amino
3. Skeletal muscle mass is reduced.
4. Albumin is the principal secretory protein of the
liver. Its depletion is common in cancer and
results in hypoalbuminemia.
5. Negative nitrogen balance occurs in spite of
Severe metabolic changes can cause progressive
weight loss, protein energy malnutrition, anaemia
and other abnormalities in protein, fat and
carbohydrate metabolism. This Syndrome is known
as cancer cachexia.
Fluid and electrolyte
• Fluid and electrolyte imbalances are seen in
advanced cancer patients. Severe vomitting
diarrohoea and changes affected in the enzyme
system could elicit many symptoms.
• Hypercalcemia is one of the most common
• The common symptoms are nausea, muscle
weakness, excess urine, elevated blood pressure,
anorexia, lethargy, confusion and stupor
progressing to coma.
• On the other hand, certain type of tumors reduces
calicitrol concentration in conjunction with
hypophosphatemia, thereby inducing an oncogenic
• Muscle weakness of varying degree and back pain
have been the frequent complaint.
1. Anorexia with progressive weight loss and
2. Taste changes causing depressed or altered food
3. Alterations in protein, carbohydrate and fat
4. Increased energy expenditure despite weight loss.
5. Impaired food intake and malnutrition secondary to
mechanical bowel obstruction ,intestinal dysmotility
induced by various cancerous tumors.
6. Malabsorption associated with deficiency or inactivation of
pancreatic enzymes, bile salts, failure of food to mix with
digestive enzymes; fistulous bypass of small bowel,
infiltration of small bowel wall or lymphatic and mesentery
by malignant cells.
Blind loop syndrome ( blockage of small intestine resulting
in stasis of the movement of food or digestive secretions)
occurring with depressed gastric secretion or partial upper
small bowel obstruction leading to bacterial overgrowth;
malnutrition induced villous hypoplasia.
7. Anaemia of chronic blood loss and bone marrow
8. Electrolyte and fluid problems with persistent
vomiting associated with intestinal obstruction or
intracranial tumors, intestinal fluid losses through
fistulas or diarrhoea.
There is a wide array of methods to diagnose cancer. The most common diagnostic
A small tissue sample is surgically removed and examined under a microscope for
the presence of cancer cells. Depending on tumor location, some biopsies can be
done on an outpatient basis with only local anesthesia.
If the tumor is filled with fluid, a type of biopsy
known as a fine needle aspiration is used.
A long, thin needle is inserted directly into the
suspicious area to draw out fluid samples for examination.
A flexible plastic tube with a tiny camera on
the end is inserted into body cavities and organs,
allowing the physician to view the suspicious area.
There are many types of scopes, each designed to view
particular areas of the body. For instance, a colonoscope
is used to detect growths inside the colon, and a
laparoscope is used to examine the abdominal cavity.
• Diagnostic Imaging
Several techniques are used to produce an internal
picture of the body and its structures. Types of imaging
X-rays are the most common way doctors make pictures of
the inside of the body. Specialists can spot abnormal areas
that may indicate the presence of cancer.
CAT scan (computerized axial tomography), uses radiographic
beams to create detailed computerized pictures taken
with a specialized X-ray machine. It is more precise than a
standard X-ray, and provides a clearer image.
Magnetic Resonance Imaging (MRI) uses a powerful
magnetic field to create detailed computer images of the
body’s soft tissue, large blood vessels and major organs.
MRI is an accurate but expensive process, and patients
must lie completely still during the procedure for best
Ultrasound uses high-frequency sound waves to determine if
a suspicious lump is solid or fluid. These sound waves are
transmitted into the body and converted into a
• Some tumors release substances called tumor
markers, which can be detected in the blood. A
blood test for prostate cancer determines the
amount of prostate specific antigen (PSA).
• Higher than normal PSA levels can indicate
cancer. Recently, a blood test for ovarian cancer,
known as CA-125, has become available.
However, blood tests by themselves can be
inconclusive, and other methods should be
used to confirm the diagnosis.
OF CANCER PATIENTS
Objectives of the dietary management
- To prevent further tissue
- To meet the increased
Metabolic demands of
- To provide relief from
- To prevent progression
and promote recovery
from cancer cachexia.
• Cancer imposes increased energy demand because
of the hypermetabolic state of the disease process
and increased energy requirement to spare proteins
for tissue healing and promote weight gain.
• By the help of appetite stimulants and / or nutrition
support systems (enteral tube feeding)
malnourished patients can be motivated to
consume around 30-35 Kcal/kg body weight / day
• A high energy diet is helpful in inhibiting the sideeffects of chemotherapy and cancer cachexia.
• The protein intake must be 1.5 g/ kg /day , to
achieve a positive nitrogen balance.
• Emphasis of course should be laid on the
inclusion of high biological value protein rich
food sources as milk, eggs, marine foods, and
• During cancer there is enhanced mobilization of free fatty
acids from adipose tissues resulting in subsequent depletion
of total body fat.
• Around 15-20% of the modified energy requirements should
be provided from fat as they help in making the meals calorie
dense and improve palatability.
• Emphasis should be laid on the incorporation of emulsified
fats and vegetable oils particularly those which are rich in
medium chain triglycerides.
• Visible sources of animal fat (pure ghee, lard etc.) and flesh
food (red meat) should be restricted in diet.
• A combination of vegetable oils (olive, coconut, safflower
etc.) cream, butter etc. can help in improving taste and
providing variety in term of flavour in different meals.
• Adequate amount (60% of total energy ) of
carbohydrates should be provided.
• emphasis may be required on the incorporation of
easy-to-digest carbohydrates (mono/disaccharides and
starches) so as to make the meals small in volume and
• The fibre intake may need to be curtailed if the patient
is suffering from cancer of the gastrointestinal tract or
• However, some patients may experience
hyperglycemia. In such situations inclusion of food
particularly those which are rich in soluble fibre(pulses
and legumes) would be helpful.
Vitamins, Minerals and
• Several vitamins particularly those of the B-group are essential to
promote adequate metabolism of energy and protein.
• Vitamin A, C and E should be provided liberally as they help in
reducing the morbidity and mortality due to cancer, (required for
tissue synthesis, cell differentiation and for maintaining cell integrity).
• Among the minerals, zinc and selenium are particularly important
and their intake should be slightly increased by giving supplements.
• The role of phytochemicals (carotenoids, flavonoids, plant sterols,
allium compounds, indols, phenols etc.) is gaining importance over
the past few years.
• Incorporation of good amount of fresh fruits and vegetables
preferably with their edible peels, soyabean and certain Indian
condiments and herbs such as turmeric can help in promoting the
dietary intake of phytochemicals.
• Adequate fluid intake is imperative to replace losses
due to gastrointestinal disturbances, infection and fever
can also to help the kidney's dispose off the metabolic
breakdown products from the destroyed cancer cells,
as well as, from the toxic drugs used in the treatment.
• Adequate intake of fluids/beverages helps in providing
relief from xerostomia and other swallowing problems.
• Menu's should be planned such that they include
dishes rich in moisture and water along with a
• Textbook of human nutrition : mahtab s.
Bamji, n. Prahlad rao and vinodini reddy
• Dietitics : b. Srilakshmi
• 347 million people worldwide have diabetes.
• In 2004, an estimated 3.4 million people died from
consequences of high fasting blood sugar.
• More than 80% of diabetes deaths occur in low- and
• WHO projects that diabetes will be the 7th leading cause of
death in 2030.
• Healthy diet, regular physical activity, maintaining a normal
body weight and avoiding tobacco use can prevent or delay
the onset of type 2 diabetes.
• Type 2 accounts for around 90% of all diabetes worldwide.
Reports of type 2 diabetes in children – previously rare –
have increased worldwide.
• In some countries, it accounts for almost half of newly
diagnosed cases in children and adolescents.
• India is the Diabetes capital of the world with
Hyderabad is the Diabetes capital of India.
• November 14 - World Diabetes Day.
• One in every five diabetics in the world is
India now has 35 million Diabetics.
• Diabetes has no cure.
• In diabetes an inadequate utilization of the blood
sugar occurs. Hence, there is a rise in blood sugar
• If the blood sugar rises above the level of 180
mg/100 ml in the blood, then the sugar is excreted
in the urine also.
• Diabetes cannot be cured but changes in life style,
and diet and drugs can make an individual lead a
• Several forms of diabetes have been identified as a
result of research and survey conducted worldwide. These forms of diabetes include:
• Type 1 - Insulin Dependent Diabetes Mellitus
• Type 2 - Non Insulin Dependent Diabetes Mellitus
• Type 3 - Malnutrition Related Diabetes Mellitus
• Impaired Glucose Tolerance (IGT)
• Gestational diabetes
Type 1 - Insulin Dependent Diabetes
• Mostly children and adolescents suffer from this type
of diabetes however, it may appear in adults and
elderly too. In this, there is little or no production of
insulin by β cells of the pancreas.
• Hence the young individuals require daily insulin
injections. If daily injection is not taken, there could be
life threatening metabolic complications and the
symptoms could be very severe.
• Since various types of insulin are available (short term
and long term), the carbohydrate content of the diet
has to be adjusted accordingly.
• More people are underweight in this type of diabetes.
Type 2 - Non Insulin Dependent
Diabetes Mellitus (NIDDM)
• Overweight and obese adults are generally afflicted
by this type of diabetes.
• The Insulin produced by the pancreas is normal or
• The symptoms of the disease are gradual.
• The problem is caused by insulin resistance.
• Obesity is the main cause of insulin resistance .
• weight reduction, diet and exercise can be helpful
to decrease the insulin resistance. Anti-diabetic
drugs can also be useful.
Type 3 - Malnutrition Related Diabetes
• This type of diabetes has been categorized as a
• It is seen commonly in developing countries, India
being one of them.
• It occurs in the young mostly between the ages of
15-30 years. People look thin, lean and
• The reason for this type of diabetes is that the
pancreas does not produce enough insulin(necrotic
tissues on the pancreas )and hence these
individuals require insulin.
Impaired Glucose Tolerance (IGT)
• Glucose tolerance is assessed by taking the fasting
blood sugar value.
• An oral glucose load of 75 grams glucose is
administered and blood sugar value checked again after
1 1/2 - 2 hrs. The value of sugar obtained is checked
against the normal or fasting value.
• If values are above normal, then we describe the
condition as impaired glucose tolerance.
• In this type, the individuals are free from the symptoms
of diabetes but they could develop diabetes at a later
stage if they are unable to control the diet and avoid
• Regular exercise also helps in maintaining the blood
• When a pregnant woman develops diabetes, it is
known as gestational diabetes.
• It occurs in only 1% of the pregnant women.
Pregnant women who have a risk of diabetes
because of family history or bad obstetrics history
should be screened for diabetes.
• Pregnant mothers develop diabetes related
complications and after delivery can also continue
with the diabetic conditions.
Etiology of Type I Diabetes
Type II diabetes
• Besides some of the genetic and environmental
factors, imbalance of hormones can cause this type
of diabetes many of these hormones may be insulin
antagonist. These hormones include:
• Growth Hormone: About 1/3rd of diabetics have
been shown to have excess growth hormone.
• Adrenocortical Hormone: Cortisol and
corticosteroids lead to an increased protein
breakdown and inhibit sugar utilization by the
tissues, thus increasing blood sugar levels.
• Adrenaline: This hormone increases the
breakdown of glycogen (the storage form of
glucose) in the liver. It also suppresses the
insulin secretion thus increasing the blood
• Thyroid hormone: Excess thyroid hormone
• Gestational Diabetes is the temporary
diabetes seen in pregnancy.
• This is due to increased production of
hormones which are antagonistic to insulin
Metabolic Aberrations and Symptoms
• Three major effects of diabetes on the metabolism
1. Decreased utilization of glucose by the body cells
with a resultant increase in the blood sugar levels
to ranges between 300 to 1200 mg/dl. Thus the
carbohydrate metabolism gets affected and the
body cells do not get the fuel for energy purposes.
2. Markedly increased mobilization of fats from the
fat storage areas, causes abnormal fat metabolism,
as well as, deposition of lipids in vascular walls that
• Thus, the body depends more on energy derived
from fat than that derived from carbohydrates.
when this happens, the level of acetone, aceto
acetic acid and hydroxybutyric acid in the body
fluids rises thus causing a condition known as
• A second effect which is even more important is the
direct increase of ketoacids.
• These ketoacids have a low threshold for excretion by
the kidneys. as much as 100-200 grams of ketoacids
can be excreted in the urine each day.
• Because these are strong acids, they combine with
sodium derived from the extracellular fluid replacing
the extracellular fluid sodium with hydrogen ions,
thereby making the urine more acidic.
• This causes rapid and deep breathing. these extreme
effects occur in severe or poorly managed diabetes,
leading to acidic coma and even death.
3. The third effect is on the depletion of protein in
tissues of the body causing changes in the protein
• The catabolic activity of muscle protein is
accelerated in diabetes leading to increase in
nitrogen that must be excreted after deamination.
• Also the cellular potassium in the blood is increased
which needs to be excreted in the urine.
• Certain diagnostic tests help in understanding
the previous history of a diabetic and also in
preventing the onset of future complications
• These are:
• The Oral Glucose Tolerance Test (OGTT)
• Urinary Sugar Test (Benedict's Test)
• Glycosylated Haemoglobin Test
Oral Glucose Tolerance Test (OGTT)
• most commonly used diagnostic test particularly
for identifying new and 'at risk' individuals
• This test is carried out after fasting overnight (12
hours). Glucose, 75 g in adults and 1.75 per kg
body weight in children, is administered orally
(dissolve in glass of water).
• Before the glucose load and 2 hours after the
blood samples are taken and estimated for sugar
• In normal individuals free from diabetes and
with no impaired glucose tolerance, the
fasting sugar levels are between 80-100 mg/
Urinary Sugar (Uristix Benedict's test)
• In diabetics, glucose is excreted by the kidneys when the
blood sugar levels are more than 180 mg /dl. This is known
as the renal threshold.
• Varying amounts of glucose is found in the urine depending
on the severity of diabetes and also the intake of
carbohydrates. This test is not as reliable as the blood sugar
test since reducing sugars such as lactose (in lactating
women) can give a positive test which is not related to
• Today, commercially diagnostic strips (uristix) are
available with the chemists. The strip is dipped in the
urine and the colour change on the strip indicates the
sugar level in the urine.
• Another method of checking sugar in the urine is
called the Benedict's test. In this test, eight drops of
urine and 5 ml of Benedict's solution are taken in a test
tube, mixed and heated for 5 minutes. Change of
colour indicates sugar in the urine.
• Self monitoring by this method can be done several
times if diabetes is severe (blood sugar levels at 180
mg,or more per 100 dl). It is better to carry the test in
the morning in the second urine sample. Urinary
sample will more or less reflect the blood sugar level.
• currently one of the best ways to check whether diabetes is
under control or not.
• higher the value the poorer has been the management.
• based upon the concept that excess blood sugar level
circulating in the blood gets attached to the pigment
(haemoglobin) present in the red blood cell (RBC) to make a
glycosylated haemoglobin called Hb A1C,
• This deposit increases with the degree of diabetes. The
combined glucose and haemoglobin in RBC can be
• This level is high in diabetics (8-18% range) as compared to
normal individuals (4-7% range).
• The glycosylated haemoglobin reflects the trend of sugar
levels in the blood during the past 2-3 months.
• Patients having high values should be identified as the
target groups for rigorous counselling regarding
management of hyperglycemia.
Complications of Diabetes
• A. Acute Complications of Diabetes
1.Hypoglycemia or low blood sugar:
• most frequent cause of low blood sugar is poor timing of meals and
• the treatment programme is based on proper balance of insulin, food
consumption and exercise.
• by reducing the food intake, by skipping or delaying a meal or snack, the
amount of sugar in the blood will be less than if one had followed the
• This creates a situation in which there is more insulin than needed for the
sugar in the blood. The insulin will work on whatever sugar it gets and
lower the existing blood glucose levels further.
• The second cause could be exercising more than usual without adding an
extra meal or snack in the diet.
• So the usual amount of insulin and increased exercise can lower the blood
sugar level further.
• Low blood sugar can also be caused by accidentally taking too much
of insulin. When this occurs, more insulin is present in the body than
needed. The extra insulin works on glucose (sugar) already in the
blood resulting in abnormal low blood sugar.
• The symptoms of low blood sugar are called 'insulin reactions' or
'hypoglycemia'. These reactions appear suddenly and must be
• Symptoms appearing first are shakiness, nervousness, sweating,
dizziness, weakness, irritability and hunger. Symptoms that develop
further but slowly are crying, anger, drowsiness, confusion,
staggered gait, inability to complete work, blurred vision and
• If the above are not treated immediately, more serious symptoms
may eventually develop. These are increased confusion, delirium,
convulsions and unconsciousness. If the individual is conscious,
encourage him/her to eat a fast acting carbohydrate, such as sugar,
honey, sweet or a chocolate and coca cola.
• Stop all activity and allow to rest for 10-15
• The glucose in the food should raise the blood
sugar levels quickly. If not, try the second time. If
unconscious, a friend, a family member should
come to the rescue.
• The individual may need an injection of glucagon
(glucagon is a hormone like insulin but produced
by the alpha cells of islets' of Langerhans and the
pancreas). It has an action opposite to that of
insulin as it increases blood sugar.
Hyperglycemia (abnormally high blood
• This condition occurs when there is not enough insulin to meet the
body needs and the deficiency is allowed to continue uncorrected.
• With high sugar levels in the blood, the sugar in the urine is
excreted at high levels. In addition, the body breaks down fat for
energy and ketones are made.
• Increased production of ketones is known as ketosis and their
elevated levels in blood is referred to as ketonemia.
• Their increased excretion in urine is referred to as ketonuria and the
term ketoacidosis includes disorders associated with enhanced fat
break down. Ketoacidosis is an extremely serious condition which
can cause "Diabetic coma" or even death.
• The onset of ketoacidosis is gradual but when ketones are present,
it is important to test for both glucose or ketones in the urine.
How Ketoacidosis develops?
• The chain of reaction begins with insufficient insulin to
meet the needs of the body. Several factors then work
together. These include:
1. Illness, infection, injury or emotional stress could increase
the body's need for insulin because of the extra energy
required. Effectiveness of available insulin would also
require release of additional glucose from liver (already
stored as glycogen) or from fat sources.
2. Omitting insulin doses, which reduce the amount of insulin
available to the body.
3. Reducing exercise thereby upsetting the food, insulin and
exercise balance. This factor and other factors given above
may aggravate the tendency towards ketoacidosis.
4. Excessive amounts of carbohydrate food may also aggravate
B. Chronic complications
• These occur gradually when the diabetics do
not monitor the blood sugar and they are
careless about eating, exercise and the
medications as a result of which the blood
sugar levels are high.
• Uncontrolled diabetes with circulating high
sugar and lipids precipitate vascular disease.
• Degeneration of walls of the arteries due to
fatty plaques deposition on arterial walls
Diabetics are more prone to myocardial
infarction, stroke and deep artery blockages in
• Atherosclerosis is a common complication in
the diabetics. Lipoprotein abnormalities are
common in diabetics and responsible for this
• Changes occur in the nephrons of the kidney
due to thickening of capillary basement
membrane, leading to glomerulonephrosis
(disease of kidneys).
• These changes lead to defects in filtration
increasing the proteins in urine (protein urea)
and causing uraemia and finally renal failure.
• Long duration diabetes with uncontrolled
sugar may affect the small blood vessels of the
• This can result in rapid deterioration of the
• Lesions of peripheral nervous system
(neuropathy) could cause tingling, burning or
numbness in the sensation of the upper and
• Diabetics are also prone to various bacterial, viral and
• diabetics cuts and wounds heal slowly.
• Individuals are prone to tuberculosis, infections of the
skin, urinary tract and foot.
• The doctor must be consulted and appropriate
• Foot care is most important as the common problems
related to the foot are lack of circulation and
• In 5% diabetics, amputation is necessary due to
DIETARY GOALS IN DIABETES
1. supply optimum nutrition to maintain good
2. provide calories for maintaining ideal weight and
allowing the normal growth and development (in
case of children),
3. maintain blood sugar control (glycemic control),
4. achieve optimum blood lipid levels, and
5. minimize acute and chronic complications of
• The energy requirements of adult patients is
governed by their present body weight and
the need to maintain a desirable or ideal body
• Proteins should be provided in adequate amounts to
maintain normal body composition and prevent
depletion of lean tissue mass.
• Adult diabetics without any complications are able to
maintain good health when given 1.0 gm protein/ kg
ideal body weight per day.
• During childhood, adolescence, pregnancy and lactation
the requirements are higher than the RDI and patients
usually benefit by increasing the protein by 10 to 15%.
• However, in case of renal complications protein intake
needs be restricted in accordance with the clinical
parameters of renal function test. In such situations the
patient should not be given more than 0.8 gm per kg
IBW per day.
• The total fat recommended by WHO is less than 30% of
the total calories.
• However in view of the widely prevalent Asian paradox
in India, it is generally recommended not to provide
more than 15-20% of the total energy from dietary fat.
• This is particularly important in case of obese diabetics
having hypertension or cardiac disorders.
• Vegetable oils rich in mono/poly unsaturated fatty
acids should be preferred over animal fats which are
generally rich in saturated fatty acids.
• The dietary cholesterol intake should be kept
below 300 mg/day for diabetics without any
• However, if the patient is at risk or is suffering
from hyperlipidemia, the cholesterol intake
should not exceed 200 mg day.
• These to a large extent depend on the food habits.
• Complex carbohydrates with more fibre are recommended
to simple carbohydrates like sugars.
• The amount should provide 55-65% of the day's calorie
• The percentage and distribution of carbohydrate will vary
with the insulin regimens and the treatment goals and also
• diabetics need not restrict their carbohydrate intake, but
they can alter the type of carbohydrates in their diets,
• eat complex carbohydrates (whole cereals, pulses and
vegetables) and avoid foods rich in simple carbohydrates
(honey, jaggery, sugar and jams).
B. Dietary Fibre
• Dietary fibre is that part of food which is not digested by
the intestines. High fibre meals have shown to give the best
glycemic control in diabetics.
• It not only reduces blood sugar but lowers blood
cholesterol and hence is good for cardiovascular diseases,
constipation and some forms of cancer.
• Fibre is found in a wide range of foods such as whole
cereals, pulses, fruits, green leafy vegetables (insoluble
fibres), Many soluble fibres such as those present in beans,
fenugreek seeds are found to be more effective
in controlling blood sugar and serum lipid levels.
• Intake of 25 g of dietary fibre per 1000 calories/day is
considered optimum for a diabetic
C. Vitamins and Minerals
• The recommendation of vitamins and minerals is
the same as for general population.
• However, lower levels of magnesium are
associated with risk of diabetes.
• Magnesium depletion has been associated with
insulin insensitivity, which may improve with oral
• Chromium supplementation has been shown to
exhibit beneficial effects in diabetic patients.
• Mineral and other vitamins supplementation
must be considered during infections and
complications or situations such as extreme
weight reducing diets, strict vegetarians,
pregnant, lactating and elderly or those
individuals who are on drugs and have
malabsorption disorders and other ailments.
• Sodium restriction is suggested for
hypertensive diabetics or those who are
suffering from renal complications/oedema.
• Textbook of human nutrition : mahtab s.
Bamji, n. Prahlad rao and vinodini reddy
• Dietitics : b. Srilakshmi