This document discusses diabetes mellitus and provides information on different types of diabetes, including type 1, type 2, and gestational diabetes. It covers the causes, symptoms, and treatment goals for each type. The document also discusses dietary recommendations for diabetes, including macronutrient distribution, use of carbohydrate counting and exchange lists, glycemic index of foods, and fiber and sodium intake. Recommendations are provided separately for type 1 and type 2 diabetes.

1. Towkir Ahmed Ove
M.S. in Food Science & Nutrition
ID : 1705421

2. Diabetes Mellitus
Diabetes mellitus is a group of diseases characterized by high blood
glucose concentrations resulting from defects in insulin secretion,
insulin action, or both. Abnormalities in the metabolism of
carbohydrate, protein, and fat are also present.
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3. 3

4. Type I Diabetes
Also called Insulin dependent diabetes mellitus (IDDM),
Juvenile-onset diabetes
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Occurs at any age, although common in younger age
group
Pancreas does not produce sufficient insulin
Patient depends on insulin, elevation of blood glucose

5. Continued
Type 1 diabetes accounts for 5% to 10% of all diagnosed cases of diabetes.
Persons with type 1 diabetes are dependent on exogenous insulin to
prevent ketoacidosis and death.
▹ type 1 diabetes has two forms: immune-mediated diabetes mellitus
and idiopathic diabetes mellitus.
▹ Immune-mediated diabetes mellitus results from an autoimmune
destruction of the cells of the pancreas.
▹ Idiopathic type 1 diabetes mellitus refers to forms of the disease that
have no known etiology. Although only a minority of persons with type
1 diabetes fall into this category, of those who do, most are of African
or Asian origin.
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6. 6
Causes
Auto
immunity
Idiopathic
Circulating
auto
antibodies
(ICAs,IAAs,
GAD)
Genetic
Factor

7. Symptoms7

8. Type II Diabetes
▹ Also called as noninsulin dependent diabetes mellitus (NIDDM), adult
onset diabetes
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▹ Patient with this condition can manufacture some insulin but do not
make sufficient amount or cannot use insulin efficiently
▹ Persons with type ΙΙ are not insulin dependent, some of them use
insulin because of persistent hyperglycemia
▹ Most of these persons are obese

9. Continued
▹ Type 2 diabetes may account for 90% to 95% of all diagnosed cases of
diabetes and is a progressive disease that, in many cases, is present
long before it is diagnosed.
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10. 10
Causes
Environm
ental
factors
Intake of
excessive
calories
Risk
factors(
physical
inactivity,
older age,
obesity
Genetic
Factor

11. Gestational diabetes
▹ Gestational diabetes is hyperglycemia with blood glucose values above
normal but below those diagnostic of diabetes, occurring during
pregnancy.
▹ Women with gestational diabetes are at an increased risk of
complications during pregnancy and at delivery. They and their
children are also at increased risk of type 2 diabetes in the future.
▹ Women with known diabetes mellitus before pregnancy are not
classified as having GDM.
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12. Other Types of Diabetes
This category includes diabetes associated with specific genetic syndromes,
surgery, drugs, malnutrition, infections, and other illnesses. Such types of
diabetes may account for 1% to 2% of all diagnosed cases of diabetes.
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Impaired Glucose Homeostasis
A stage of impaired glucose homeostasis includes IFG (Impaired Fasting
Glucose) and IGT(Impaired Glucose Tolerance) and is called pre-diabetes.
This condition can be detected by either a fasting plasma glucose (FPG)
test or an oral glucose tolerance (OGT) test. Individuals with pre-diabetes
are at high risk for future diabetes and cardiovascular disease.

13. The recommendation for dietary therapy in
diabetes mellitus aims at the following goals
1) Attain and maintain optimum nutrition and ideal body weight.
2) Maintain blood glucose concentration as close to the normal range as
possible.
3) Prevent or delay development of diabetic complications, i.e. diabetic
microangiopathy, premature atherosclerosis and neuropathy.
4) Make the diet as attractive as possible without compromising goals 1-3.
5) Make the diet prescription as close to the food preferences and eating
habits of the non-diabetic population as possible without compromising
goals 1-3.
6) Make the price of the diet reasonable
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14. GENERAL RECOMMENDATIONS OF THE AMERICAN
DIABETES ASSOCIATION
The American Diabetes Association currently makes the following nutritional
recommendations for people with diabetes :
1. Achieve and maintain ideal body weight.
2. Derive 55 to 60 per cent of total caloric intake from carbohydrates.
3. Consume foods containing unrefined carbohydrate with fiber, attempting
to take in 40 g of soluble fiber per day.
4. Consume only "modest" amounts of sucrose and then only if it can be
demonstrated that sucrose does not adversely affect individual metabolic
control or body weight.
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15. Continued
5. The use of various other nutritive and non-nutritive sweeteners is
acceptable.
6. Limit protein intake for adults to 0.8 g per kg of body weight.
7. Restrict fat intake to 30 per cent or less of total calories, with saturated
fat and polyunsaturated fat each accounting for less than 10 per cent of
total calories (monounsaturated fat to account for the remainder of fat
intake).
8. Restrict cholesterol intake to less than 300 mg per day.
9. Restrict sodium intake to 1.0 g per 1000 kilocalories (not to exceed 3.0
g per day).
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16. PRIMARY GOALS: TYPE I DIABETES MELLITUS
▹ The meal pattern usually includes breakfast, lunch, dinner, and a
bedtime snack. Some individuals also may require a mid-morning or
mid-afternoon snack.
▹ The best means for someone with type I diabetes to achieve dietary
consistency is through the use of the Exchange Lists for Meal
Planning.
▹ The Exchange Lists established six food groups (starch, meat,
vegetable, fruit, milk, and fat) with the intent that one food in a group
could be interchanged during meal planning with an equivalent
portion of another food in the same group.
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17. Continued
▹ To use the Exchange Lists, a dietitian or physician first determines the
caloric needs of her or his patient based on age, sex, level of physical
activity, and desirable body weight.
▹ In order to calculate ideal body weight Broka’s index is used. This
measurement is easy to calculate and accurate.
▹ Brokas’s Index = Height (cm) – 100 = ideal weight (Kg)
▹ A second important dietary goal in treating patients with type I diabetes
mellitus is to avoid undesirable weight gain.
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18. Continued
▹ The recommended calorie intake for a diabetic based on body
weight is as follows :
▹ over weight individual - 20 kcal / kg.wt/day.
▹ ideal weight - 30 kcal / kg.wt./day.
▹ underweight - 40 kcal / kg.wt/day
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19. 19

20. 20

21. Continued
▹ A more effective strategy to eliminate the nocturnal hypoglycemia
(particularly if the hypoglycemia is early in the night and weight gain has
not been a problem) might be to increase the patient's bedtime snack.
Ice cream can be particularly effective in this regard because of the
modest and sustained rise in blood glucose that it produces.
▹ Similarly, if a patient is experiencing hyperglycemia before lunch, it
might be more effective (particularly if weight gain has been a problem)
to reduce the carbohydrate content of the breakfast meal rather than to
increase the dose of prebreakfast regular insulin.
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22. PRIMARY GOALS: TYPE II DIABETES MELLITUS
▹ Approximately 80 per cent of people with type II diabetes are
overweight. Weight loss is the most important therapeutic goal in such
individuals and almost always is associated with improved carbohydrate
tolerance.
▹ The panel recommended that obese patients with type II diabetes be
maintained on a balanced diet "moderately restricted in calories.
▹ level for such a diet can be calculated by determining the weight
maintenance calorie level from desirable body weight and estimated
physical activity as described in the section on type I diabetes.
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23. Continued
▹ From the weight maintenance calorie level, subtract 500 kilocalories
per day to determine the calorie level that will accomplish weight loss
of approximately 1 lb. per week.
▹ For those morbidly obese patients who are unable to lose weight or
unable to maintain weight loss, gastric reduction surgery may be
considered; however, such patients should meet the criteria listed
previously.
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24. Glycemic Index
▹ The glycemic index indicates the extent of rise in blood sugar in response
to a food in comparison with the response to an equivalent amount of
glucose.
▹ Glycemic Index = (Blood glucose area of test food/Blood glucose area of
reference food) x 100
Factors that affect the glycemic response to food are
1. Rate of ingestion of food
2. Food form
3. Food components – fat content, fiber content, protein content.
4. Method of cooking and processing food.
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25. Continued
▹ Since the blood sugar level depends mainly on the intake of
carbohydrate it is important to distribute the intake of carbohydrates.
The total amount of carbohydrates is divided in to 4-5 equal parts.
I. One third (33%) is served during lunch,
II. one third (33%) during dinner.
III. Of the remaining one third (33%), 25% is served during breakfast and
9% at tea or bed time.
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26. Carbohydrates
▹ Complex carbohydrate found in cereals and pulses are given. These
are then broken down into simple sugars before they are absorbed
from the gut.
▹ Refined carbohydrates such as sugar, honey, jaggery and jam contain
simple sugars which are directly absorbed are not recommended for
diabetics, as they cause a rapid rise in blood sugar.
▹ Sugar present in fruits and milk raise the blood sugar at a slightly lower
rate. Whole apple is better than apple juice because of its high fibre
content and low glycemic index.
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27. Continued
Numerous factors influence glycemic responses of foods,
▹ including the amount of carbohydrate,
▹ type of sugar (glucose, fructose, sucrose, lactose),
▹ nature of the starch (amylose, amylopectin, resistant starch),
▹ cooking and food processing, particle size,
▹ Food form as well as the fasting and pre-prandial glucose
concentrations,
▹ severity of the glucose intolerance,
▹ and the second meal or Lente effect of carbohydrates.
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28. Sweeteners
▹ If sucrose is included in the food and meal plan, it should be substituted
for other carbohydrate sources or, if added, be adequately covered
with insulin or other glucose-lowering medications.
▹ Sorbitol, mannitol, xylitol, isomalt, lactitol, and hydrogenated starch
hydrolysates are common sugar alcohols that also have a lower
glycemic response and lower caloric content than sucrose and other
carbohydrates.
▹ It is unlikely, however, that sugar alcohols in the amounts likely to be
ingested in individual food servings or meals will contribute to
significant reduction in total energy or carbohydrate intake (ADA,
2002b).
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29. Continued
▹ Some patients report gastric discomfort after eating foods
sweetened with these products, and consuming large quantities
may cause diarrhea.
▹ The two artificial sweeteners in common use in the United States at
present are aspartame and saccharin.
▹ Although aspartame is composed of two amino acids (L-phenylalanine
and L-aspartic acid) and technically is a nutritive sweetener, it is 180 to
200 times sweeter than sucrose).
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30. Continued
▹ Thus can be used in such small amounts in foods and beverages that its
caloric contribution usually is negligible.
▹ Aspartame is stable at cool temperatures but decomposes at high
temperatures and thus is not suitable for use in baked goods.
▹ Saccharin is a derivative of toluene, which is more than 300 times
sweeter than sucrose.
▹ For all food additives, including nonnutritive sweeteners, the FDA
determines an acceptable daily intake (ADI), defined as the amount of a
food additive that can be safely consumed on a daily basis over a
person’s lifetime without risk
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31. Protein
▹ A diet rich in protein has usually been recommended for diabetics, as
dietary protein has been thought to protect from hypoglycemia by
providing substrate for gluconeogenesis.
▹ In type 2 diabetic patients who are still able to produce insulin, ingested
protein is just as potent a stimulant of insulin secretion as carbohydrate.
▹ It is recommended that 15 – 20% of total calories be derived from
proteins.
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32. Continued
▹ There is evidence that moderate hyperglycemia in persons with type 2
diabetes and uncontrolled diabetes in persons with type 1 diabetes
cause increased protein catabolism.
▹ Protection against increased protein catabolism requires near-normal
glycemia and an adequate protein intake.
▹ Therefore, for persons with diabetes, the protein requirement may
be greater than the recommended dietary allowance.
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33. Dietary fat
▹ In all persons with diabetes less than 10% of energy intake should be
derived from saturated fat and dietary cholesterol intake should be less
than 300 mg per daily .
▹ Low fat diet increases insulin binding and also reduces LDL and VLDL levels
and reduces the incidence of atherosclerosis which is more common in
diabetics.
▹ For persons who need to lose weight, a low energy intake and a low fat,
moderate – carbohydrate approach can be used.
▹ For persons who do not need to lose weight, a high monounsaturated fat
approach may be recommended to improve triglycerides or post prandial
glycemia.
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34. Plant stanols and sterols
▹ Intake of 2 to3 g of plant stanols or sterols per day are reported to
decrease total and LDL cholesterol levels by 9% to 20%.
▹ Use of low fat food and fat replacers or substitutes approved by the
FDA are safe for use and may reduce total fat and energy intake.
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35. Dietary fiber
▹ Intake of 25g of dietary fiber per 1000 kilocalories is considered
optimum for a diabetic.
▹ High fiber foods have a low caloric value and low glycemic index and
therefore diabetics should consume such foods liberally.
▹ Fiber present in vegetables, fruits, legumes and fenugreek seed is
soluble in nature and more effective in controlling blood sugar and
serum lipid than insoluble fiber present in cereals.
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36. Sodium
▹ The recommendation for the general population to reduce sodium to
less than 2,300 mg/day is also appropriate for people with diabetes.
▹ For individuals with both diabetes and hypertension, further reduction
in sodium intake should be individualized.
▹ Incrementally lower sodium intakes (i.e., to 1,500 mg/day) show more
beneficial effects on blood pressure.
▹ however, some studies in people with type 1 and type 2 diabetes
measuring urine sodium excretion have shown increased mortality
associated with the lowest sodium intakes, therefore warranting
caution for universal sodium restriction to 1,500 mg in this population.
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37. Alcohol
▹ The effect of alcohol on blood glucose levels depends not only on the
amount of alcohol but also on its relationship to food intake.
▹ In the fasting state, alcohol may cause hypoglycemia in persons using
exogenous insulin or insulin secretagogues.
▹ It also blocks gluconeogenesis an augments or increase the effect of
insulin by interfering with the counter regulation response to insulin
induced hypoglycemia.
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38. Continued
▹ Pregnant women and patients with medical problems such as
pancreatitis, advanced neuropathy, severe hypertriglycemia or alcohol
abuse should avoid alcohol.
▹ If individual choose to drink alcohol, daily intake should be limited to
one drink for adult women and two drinks for adult men (One alcohol-
containing beverage is defined as 12 oz beer, 5 oz wine, or 1.5 oz
distilled spirits, each containing approximately 15 g of alcohol).
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39. Conclusions
▹ Dietary management of diabetes mellitus can be successful only if the
prescription is flexible, attractive, economical and close to the food
preferences of the community in which the patient is living.
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40. Thank You