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| ORIGINAL ARTICLE |
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| Year : 2018 | Volume
: 6
| Issue : 2 | Page : 48-52 |
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Diet in diabetes: Conceptual and contextual
Swapan Kumar Paul1, Amrita Ghosh2, Ranabir Pal1, Shrayan Pal3
1 Department of Community Medicine, MGM Medical College and LSK Hospital, Kishanganj, Bihar, India
2 Department of Biochemistry, Medical College, Kolkata, West Bengal, India
3 Department of Dermatology, Venereology and Leprosy, MGM Medical College and LSK Hospital, Kishanganj, Bihar, India
| Date of Web Publication | 26-Feb-2019 |
Correspondence Address:
Amrita Ghosh
Department of Biochemistry, Qtr. No. B1, J.N.M. Doctoræs Quarters (Opposite ESI hospital) Kalyani, Nadia - 743 512, West Bengal
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/JIHS.JIHS_18_18
Background: Emerging concepts of interventions in diabetic diets should have been targeted to preserve health and nutritional status for the “living with disease philosophy.” Objective: In search of holistic dietary practice guidelines, the authors emphasized conceptual and contextual module for all levels of health-care providers for the optimum care of diabetics. Materials and Methods: Twenty-four research studies were identified from 45 potentially relevant databases and published literature to collate an updated idea of diabetic diet. Studies were selected on; first, all emerging nutritional plans and corresponding diets in diabetes mellitus among published literature were sketchily searched; second, “Diabetic diets” impacting disease control, retain health, and nutritional status affecting prognosis in downstream morbidities were identified; third, published reports from apex bodies of global importance such as American Diabetes Association, World Health Organization, Centre for Disease Control, Atlanta, USA, and others were given due weightage for their conceptual and contextual framework. Results: We have assembled diversity and novel concepts in diabetic diets, keeping tailor-made nutritional requirements as the mainstay in the philosophy of all-inclusive regimes for this chronic disease. There is a paucity of qualitative translational researches on diabetic diets and often limited to on paper suggestions and devoid of feedback on compliance from stakeholders. Conclusions: In a holistic approach, we require more research about diabetic diet; these are very useful in daily family medicine practices for the improvement in clinical approach and treatment in patients with diverse downstream morbidities of this complex entity.
Keywords: Diabetes, diet, nutrition
How to cite this article:
Paul SK, Ghosh A, Pal R, Pal S. Diet in diabetes: Conceptual and contextual. J Integr Health Sci 2018;6:48-52 |
| Introduction | |  |
A balanced diet plan is important for every individual, more so if a person has diabetes. All diets basically consist of carbohydrates, fat, and protein. They provide energy to allow body cells to function appropriately. Manipulation of diet in diabetes, both quantitatively and qualitatively, can be helpful in controlling diabetes to a great extent. Counting of carbohydrate in diet is the most important tool to control blood glucose. A dietician can advise how counting can be incorporated into one's lifestyle.[1] The authors emphasized the optimum planning of diabetic diets in lifelong care of the diabetics with a holistic approach.
| Materials and Methods | | |
Researchers of this review endeavored a comprehensive, annotated assemblage of published literature by probing various resources as follows: field studies, meeting presentations, and personal communications about studies not included in previous analyses in which diets in diabetes were reported. Through an extensive search in indexed literature and website-based population survey reports, we identified 24 research publications from 45 potentially relevant articles. All published articles in indexed journals available from various institutional libraries of India and websites on diabetic diets. The search terms included combinations of MeSH terms and empirical taxonomies from diets in diabetes explored in PubMed-Entrez, Cochrane Library, Web of Science and the World Health Organization (WHO) Global Health Library, including searching of abstracts from scientific meetings. In the absence of monolithic pattern of reporting and nationally representative database, reports on diabetic diets from Indian research groups were considered.
Selection criteria
First, the study reports of diets in diseases among research literature were sourced; second, reports containing “Diabetic diets” impacting diagnosis and prognosis of diseases were identified and collated from all the sources; and third, globally, published information from apex bodies, for example, American Diabetes Association, WHO, Centre for Disease Control, Atlanta, USA, and others were given due weightage for their multi-authored and multidisciplinary authenticity.
Primary outcome variables: Diets for management and prognosis of diabetes mellitus.
| Results | | |
We have gathered a range of novel concepts in diabetic diets from published literatures and available vast communications, which needs further translational researches.
Living with disease
On the premises of various nutritional contents of the foods available in different geographical locations as well as the caloric content and texture diet has to be altered in diabetes. In the therapeutic parlance, a ready-made dietary schedule at times may become unacceptable to the individuals suffering from diseases for the rest of their lives with limited empathetic calorie exchange scope. There are numerous reasons for imbalance in glycemic levels of the diabetic patients, namely, anorexia, weakness, loneliness, self-pity, and many other factors including cooking practices and customs of food habits. In such cases, one has to be tactful and compassionate so that patient may be convinced to eat the prescribed diet for this chronic disease related to lifestyle factors.[2],[3],[4]
Basics of diabetic diet
The main goal of administering diabetic diet is to see that there are no upward trends in blood sugar. Many people think that cutting off sugar and carbohydrate completely from diet is the only way out. Contrary to this, it is a known fact that everyone requires getting 40%–60% of the daily requirement of calories from carbohydrate; hence, it is only the adjustment of amount as well as its uniformity of carbohydrate in diet, which is important in controlling blood sugar. Hence, it is imperative that all patients with diabetes must include varied items of food in their diet regularly. It is therefore important that instead of depleting certain items completely from diet, one must give a sincere thought to increase vegetables and fruits, and at the same time, decrease amounts of fats and sugar along with a regular workout schedule.[5]
Blood sugar shows spike mostly by carbohydrates in diet, so knowledge of foods contains an amount of carbohydrates in a diet will certainly be helpful for blood sugar control. As such, carbohydrate sources such as vegetables, fruits, and high-fiber whole grains will have an edge over sources of carbohydrate with added fats, sugars, and salt. Fats also can be a part in diabetic diet to make it balanced, but one must keep in mind to include only the healthy fats (polyunsaturated fatty acids) such as olive oil and fatty fish. The third basic group in diet is protein, which also must be included in diabetic diet to make it balanced. Proteins are more important part of a diabetic diet as they do not increase blood sugar such as carbohydrates and also give feeling of fullness. Only one has to keep a vigil on its portion in diet, to prevent weight gain. In people with Type 2 diabetes, protein makes insulin work faster; hence, it may not be a noble idea to treat low blood sugar with protein preparations. Healthy diet plan with regular physical workout and diabetes medications can help you keep your blood sugar level in target range. Hence, it is important to keep a watch on what you eat, how much you eat, and when you eat. At times, it becomes challenging for newly diagnosed diabetics to keep a balance between physical activity and complex diet plan but slow and steady can ease the situation soon. It is sometimes misunderstood that people with diabetes should restrict their diet by excluding good and favorite foods, but contrary to this, one must have regular, healthy meals choosing from the food groups such as (1) grains and starches, (2) vegetables, (3) fruits, (4) milk and milk products, and (5) meat. Healthy diet and physical activity are important to stay healthy more so when one has diabetes.[6],[7]
In short, the aim of diabetes management is long-term diet plan either low carbohydrate, Ketogenic, vegetarian, vegan, or by carbohydrate counting or by ingenious mixing of all of them. There is no single diet plan which will suit all. Whichever diet plan is selected, it must be ensured that it should be so formulated that it has to provide all the essential nutrient (balanced). Weight reduction may be added benefit.
Low-carbohydrate diet
Low-carbohydrate diet has been the mainstay in diabetic management since time immemorial and was among the first treatments of diabetes, much before the discovery of insulin. It has been observed that following low-carbohydrate diet, the requirement of medication, including insulin decreases considerably. Further, in overweight and obesity in diabetes, reduction of weight is a part of management to improve sensitivity to medications. This is done by decreasing the calorie intake to a level to force the body to use its own fat stores. Low-carbohydrate diet is advised in persons with body mass index 30 and above, by reduction to 800 calories/day consumption to lose 1–2 kg/week. However, low-carbohydrate diets are not suitable for gestational diabetes, lactating women, children, adolescents, elderly persons, and with comorbidities. High-calorie foods, namely, whole milk, butter, cream, cream soups or gravies, hard and soft drinks, salad dressings, meats, candy, and desserts are to strictly avoided. Limit these food items: milk and yogurt; whole fruit and natural fruit juice; bread, rice, crackers, and cereal; beans and other plant-based proteins; and starchy vegetables and corn.[8],[9]
Carbohydrates and the glycemic index
The glycemic index (GI) is a way to classify foods and drinks according to their ability to raise glucose level after ingestion which replaced classifying carbohydrates as “simple” or “complex.” However, one must keep in mind that low-GI rating does not give liberty to eat low-GI foods in huge quantities and the diet to be planned having plenty of fruits, vegetables, and legumes to have eucaloric diet. Food items based on GI category: low GI (<55); soy products, beans, fruit, skimmed milk, pasta, multigrain bread, porridge, and lentils; medium GI (55–70) – citrus juice, honey, basmati rice, and brown bread; and high GI (>70) – potatoes, white bread, and short-grain rice; optimum mix of low-, medium-, and high-GI foods having the effect of “averaging” the GI, for example, cornflakes (high-GI food) taken with milk (low-GI food) reduces the effect on blood sugar levels; similarly, potato and refined grain products can be taken together.[10] It is interesting that everyone wants to get suggestion on low-calorie diet, even zero calorie, which is next to impossible. However, there are food items with very low calorie; these are called as “free foods” (25 calories or less per reasonable serving) and “almost free food” (25–60 calories per reasonable serving). Here, also portion control is very important as, if the portion is not controlled, calories may exceed, especially in case of “almost free foods.” For example, 94% fat-free microwave popcorn may contain only 40 calories.[11]
Ketogenic
The main focus of ketogenic diet is to see that diet of diabetics should be low carbohydrate (under 30 grams) and low protein to an extent that it produces ketone. In the ketogenic diet, calorie comes from animal and plant fats, which make the person feeling full. Here, one has to remember that all ketogenic diets are low in carbohydrate, but all low-carbohydrate diets do not always be ketogenic.
Vegetarian
There are plenty of variations and combinations available for vegetarian diets as follows:
- Combination of eggs and dairy – Ovo-lacto
- Diet with fish and seafood – the Pescatarian, and
- Diet consisting of milk and milk product Lacto.
Vegetarians have fruits, vegetables, bread, noodles, and food items which are mostly meet free.
Vegan
Vegan diet is strictly plant-based diet with no animal products in it. In this diet, even the products, which use animal fats, eggs, and dairy products are also excluded. Since no low-carbohydrate animal foods are consumed, a vegan diet may be higher in overall carbohydrate intake. People practicing veganism get protein from plant sources.
Carbohydrate counting
Carbohydrate counting is to have a track of carbohydrate in the diet, by which carbohydrate consumed in the diet is calculated on a daily basis. Foods that contain carbohydrate have paramount effect on blood glucose as against food containing protein or fat. By carbohydrate counting, one can know how much carbohydrate he/she has consumed and thus have an idea about his/her blood glucose level as it is fact that blood glucose level is directly proportional to carbohydrate consumption, and by this, one can adjust insulin requirement by the body on a day-to-day basis. For a person with diabetes, it is very important to know the food groups, that is, which food group contains carbohydrate, proteins, or fats, as it is mandatory to include all the groups in the diet. Carbohydrate in the diet usually comes from three food groups: starch, milk, and fruit. In many vegetables, carbohydrates available in good quantity, whereas very little carbohydrate is there in meat and fat groups. Sugars are either added in diet or may be naturally present (in fruits). There are foods that can be eaten without counting also called as free food. A free food or drink contains a serving under 20 calories and 5 g or less of carbohydrates. It has to be kept in mind that if serving contains more than 5 g of carbohydrates, it should be counted it in the diet plan. Contrary to the common thought that diabetes must avoid all forms of sugar, they can eat sugar-containing foods as long as the total amount of carbohydrates for that diet plan does not exceed. Many researchers have shown that diet containing sugar does not make the blood sugar rise more than diets of equal carbohydrate levels which do not contain sugar.[12]
Living with diabetes means eating regular, healthy meals from the five food groups – grains and starches, vegetables, fruits, milk and milk products, and meats in food-exchange concepts.
Few guidelines for healthy eating as follows:
- Family should empathize and adopt healthy eating practices keeping in Empathetic mindset about the diabetic member/s of the family
- Regular meals, with breakfast first, then lunch and dinner with a spacer time of no more than 6 h apart
- Variety should be spice of life in meal times counting polyunsaturated fatty acids, lean protein mass, whole grains and reduced-fat dairy products
- Choose fiber-rich foods such as fruits, vegetables, and whole grains as much as possible, such as brown bread, bran cereals, whole-wheat pasta, and brown rice
- Explore alternatives to meat such as lentils, beans, or tofu
- Adopt family paradigm to calorie-free liquids such as sugar-free tea, coffee, or water
- Choose sugar substitutes.
High-protein diet
A clinical study suggests that diets high in protein, independent of caloric intake, improve metabolic health, and result in less carbohydrate intake and weight loss. Protein choices in diabetics may be from the following: black beans, kidney; bean products such as baked beans and refried beans; lentils such as brown, green, or yellow; peas such as black-eyed or split peas; soy nuts; and nuts and spreads such as almond butter, cashew butter, or peanut butter.[13]
This diet is usually recommended for bodybuilding, and/or when we want to reduce appetite and hunger between meals prepared with soya, beans, nuts, fish, lean meat, and low-fat dairy products. In addition, fiber-rich carbohydrates such as whole grains and fruits and vegetables to be included. However, high-protein diet for long period may lead to bad breath, headache, constipation, cardiovascular ailments, etc.[14]
Food portion: Hands are tools
It is evident that your food choice and the quantity you eat directly related to your blood sugar level. To help manage your diabetes, you have to watch your diet closely everyday by controlling the portion size of each and every food group in the diet. Portion control skill will only come slowly by trial and error on a day-to-day basis. God is great, he has given the tools – the hands.[6]
The main aim of diabetic diet is to maintain the ideal body weight of a person, which can be obtained using the following formula:
For women
For 5 feet (152.4 cm) tall woman, weight can be taken as 100 lbs (45 kg) +5 lbs (2.268 kg) for every inch (2.54 cm). For persons below 5 feet deduct 5 lbs for every inch below 5 feet for person with large frame +10% and for small frame −10% (frame size can be decided by comparing wrist size with other women).
For men
For 5 feet (152.4 cm) tall man, weight can be taken as 106 lbs (48.081 kg) +6 lbs (2.722 kg) for every inch (2.54 cm) above 5 feet. For persons below 5 feet deduct 6 lbs for every inch below 5 feet. For person with large frame +10% and for small frame −10% (frame size can be decided by comparing wrist size with other men).[15]
Thus, there is no tailor-made diet available which is suitable for all diabetic patients, as normally food groups are mixed in such a way that there will be different foods of having different glycemic indices which will be appropriate to keep diabetes in check in that person. An experienced dietician can only chart out a suitable dietary design depending on body weight, regular medications, vocation, lifestyle, comorbidities, culture, and many other likely reasons. Nutritional counseling with regards to the diets and the physical exercises should be the mainstay with stress on the necessary and precise switchover. It is observed that in the day-to-day practice, the physicians are either ignorant or due to time constraints, fail to impart appropriate nutritional Counseling with regards to diet to the people with diabetes, whereas if serious stress is given to this, it can go a long way in helping to improve the health and life of a person with diabetes.[9],[16]
Traffic light diet (syn. stoplight diet)
Epstein et al. innovated this family-based childhood overweight research which involves a novel idea way to cut calories. Food items are divided into one of the three-color categories based on their calorie content and nutritional value. Green foods are going easy with vegetables, pulpy and juicy fruits, low-fat milk and yogurt, white fish, seafood, etc., with low calories with plenty of nutrients; yellow or amber foods are tubers, low-fat cheese, oily fish, lean meat, poultry, beans, nuts, seeds, coarse rice, pasta and high-fiber breads and cereals with reasonably high calories, yet high in nutrients; and strictly limiting red food items (except greens and yellows) with high calories with lower nutrients.[17],[18]
Concept of portion and exchange
We can use the American Diabetes Association food exchange lists to suggest portion and exchange in food servings from assorted food choices from each group of foods to introduce variety in the restricted dietary advice with due respect to likes, dislikes, and religious restrictions. To break the monotony and frustration among diabetic patients, there is a need for support from family members, relations, and acquaintances to be motivated to change their diet patterns as that of diabetic patients.[19]
| Conclusions | | |
In this review, the importance of incorporation of variety and novel concepts in diabetic diet-keeping concepts of tailor-made nutritional requirements of different groups of patients was discussed as reported by different research groups. In spite of substantial growth in health care, the qualitative researches on diabetic diets are sparse and often restricted to discharge from hospital and not reported in structured form without any community-level research on compliance on dietary advices. Humane approach toward dietary allowances in diabetic patients itself will be motivational to the careseekers to delay microvascular and macrovascular complications with optimum general nutritional conditions. The first and foremost is to make a diabetic diet plan, which will usually contain food choices to eat at every meal using, what is known as the “portion and exchange” lists that will have groups of food items having the same amount of carbohydrate, protein, fat, and calories. There are three main groups as follows: carbohydrate group, meat and meat substitute group, and fat group. Carbohydrate group contains starch, fruits, and vegetables; likewise, meat and meat substitute group have lean, very lean, and medium-fat and high-fat meat and substitute, whereas fat group has monounsaturated, polyunsaturated, and saturated fat items.[20],[21],[22],[23]
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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