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 & eatinghabits.• Insulin therapy & Self blood glucose monitoring(SBGM) integrated.• Avoid fasting & feasting.
• Individualised flexible nutrition plan to facilitatecompliance.• Regular meal timing, consistent quantity,relatively fixed composition,• Thorough review of dietary intake annually orearlier if– Unexplained growth failure,– Unexplained Hyper/ Hypoglycemia,– Excessive wt gain/ loss,– HTN, Hyperlipidemia, Nephropathy, Elevated Hb A1 C
Nutritional Intervention• Offering structure for meal planning-1. Menu based2. Exchange list based3.Carbohydrate counting (Preferred)• It includes 4 steps-1. Assessment2. Goal setting3. Intervention4. Evaluation
1. Assessment– 24 Hr recall food history– Carbohydrate intake per meals & snacks– Other factors : Timing of meals, Timing & Amountof exercise, Frequency & Rx of hypoglycemia.– Assess readiness of patient for change in diet.
• Level 2– Blood glucose reading– Maintain physical activity log• Level 3– Calculate carbohydrate: Insulin ratioi.e. Total gm of carbo. Per meal: Units of rapid actinginsulin analogue taken before meal.
• Carbohydrates– 55 % of total calorie intake– Avoid rapidly absorbed mono/disaccharides(Simple) & refined sugars likeglucose, sugar, honey etc (30%)– Encourage complex carbohydrates like starch -70%
– Wheat is preferred over rice(Acarbose : slowabsorption)– Tubers restricted– Minimum daily carbohydrate intake > 130 gmabove 1 yr of age
• Exchange system : to ensure fixed energyintake 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
• Glycemic index:– Increase in RBS following ingestion of single foodas % of increase following standard food– Glucose 100%, potato 90%, rice 72%, wheat 65%,ice cream 43%, apple 40%, soyabean & peanut20%– Food items with low glycaemic index areencouraged– Not much of significance, affected by multiplefactors
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
Type of exercise Carbohydrtes to begiven gm/hr ofexerciseFood itemMild (< 30 min) 10-15 before 1 fruitModerate (1 hr) 25Before10-15 after½ sandwich+ 1 glassmilk1 fruitSevere ( 1-2 hr) 50Before10-15 after1 sandwich+ 1 glassmilk1 fruit
• Fruits: when blood sugar is well controlled ½to 1 fruit at the expense of snacks or afterexercise• 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
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 ofdietary fat• Avoid animal fat and hydrogenated oil• Fish and chicken preferred to beef and egg
• PROTEIN:15 % of total calorie intakeif nephropathy 8-10%microalbuminuria 0.8 gm/kg/d
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
• Na - < 3 gm/day< 2.4 gm/day if HTN• Vitamins and minerals: as per regularrequirement
Hypoglycemia• Decreased food intake, increased activity• Goal: rapid normalization of blood sugarwithout use of excess food thus avoidingresultant hyperglycmia
• Management:1. Simple sugar( juice, glucose tablets)rapidly absorbed, raise blood sugar within 10-15 mins15 gms = 30 mg/dl2. Repeat RBS after 15 mins, if < 80give one exchange( 15 gm)3. Repeat after 10 mins, if > 80give 15 gm carbohydrate with protein snack orplanned meal/ snacks within 30-60 mins