Diet and medical problems

Diabetes
A. P. is a 47-year-old woman diagnosed with diabetes
5 years ago. She recently started on metformin and is
tolerating it well. The need to start medication has
motivated her to really work on losing weight and
controlling her disease. She wants to know what she
should and should not eat. The recommended diet for people with diabetes
follows the same guidelines as a normal healthy
diet.66 It should contain carbohydrate, protein, and
fat in reasonable proportions. Calories should be at a
level that promotes a healthy weight, and the diet
should be based on a variety of foods. People with
diabetes should receive individualized medical
nutrition therapy (MNT), preferably with a registered
dietitian, as needed to reach their treatment goals
(evidence level B).
The major nutrient that affects blood sugar
levels is carbohydrate in the form of sugar and
starch, as found in grains, fruits, vegetables, sweets,
and milk. The total amount of carbohydrate consumed
is more important than the source or type
(evidence level A).
Sucrose, or table sugar, does not increase blood
sugar any more than the same amount of starch,
so sucrose can be substituted for other carbohydrates
in the diet. There is no evidence to support
the avoidance of concentrated sweets as long as total
energy and carbohydrate levels are maintained. Nonnutritive
sweeteners such as aspartame, saccharin,
acesulfame potassium, and sucralose appear to be
safe at normal levels of intake (evidence level A).
Low carbohydrate diets (<130 grams/day) are not
recommended for patients with diabetes (evidence
level E).
Protein, while an insulin stimulant, does not
increase blood sugar in the amounts usually eaten.
Hyperglycemia can contribute to increased protein
turnover. However, since most adults eat much more
protein than is required, there is no need for diabetics
to increase protein intake beyond usual levels (evidence
level B). For those with any degree of chronic
kidney disease, protein intake should be limited to 0.8
grams per kg body weight (evidence level B).
Whereas dietary fat helps to modulate the absorption
of glucose, saturated fat, trans fat and cholesterol
should be limited in the diet. Saturated and
trans fats in the diet stimulate LDL cholesterol production,
and persons with diabetes are more sensitive
to dietary cholesterol than the general public. Less
than 7% of calories should come from saturated fats
(evidence level A); trans fats should be minimized
(evidence level E).66
Weight loss is recommended for all adults with
BMI  25 who have or are at risk for developing
diabetes (evidence level E). Both reduced energy consumption
and weight loss improve insulin resistance
and blood glucose levels. In patients with impaired
glucose tolerance, weight loss of 10–15% may be
sufficient to hold off frank diabetes.
Supplementation with antioxidants (vitamins E,
C and beta-carotene) is not advised due to lack of
evidence of efficacy and concern about long-term
safety (evidence level A). Chromium supplementation
in people with diabetes and obesity has not been
shown to be of benefit (evidence level E).
Treatment of hypoglycemia is best accomplished
with oral glucose or glucose-containing food. The
addition of fat should be avoided, as it retards the
absorption of the glucose. Ten grams of oral glucose
will raise blood sugar levels by ~40 mg/dL over
30 minutes, and 20 grams will raise blood sugar levels
by ~60 mg/dL over 45 minutes.67
The New American Plate may be a helpful model.
Sometimes having the patient eat on a smaller plate
helps in portion control. Patients should be encouraged
to eat more fruits and vegetables, but restrict juice and
sweetened drinks to no more than 4–6 ounces per day.
Monounsaturated fats (such as olive or canola oil)
should be used to replace saturated fats in cooking.

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