Diet and exercise in diabetes

Diet and Exercise in Diabetes
Dr Joozer Rangwala
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MNT: Medical Nutrition Therapy
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Basic Objectives of Nutrition
Recommendations:
1. To achieve ideal body weight.
2. To prevent hypoglycemia.
3. To take care of co-morbidities:
1. Hypertension
2. Dyslipedemia
3. Nephropathy. Etc…
4. Meal related glucose rise to match with insulin:
1. Endogenous or
2. Exogenous
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Steps to individualised diet planning:
• Enquire about food habits
• Calculate individuals calorie need
• Distribute calculated calories for meals as per
patients individual needs
• Diet plan meals with calorie distribution as:
– 60 – 70 % carbohydrate
– 20 % fat
– 15 – 20 % proteins
• Include all essentials nutrients and
micronutrients.
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Steps to individualised diet planning:
Step 1 Food habit information
Step 2 Calorie calculation
Step 3 Calorie distribution based on
expected treatment
Step 4 Macro – nutrients quantity
Steps 5 Menu / Diet chart
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Step 1: Food habit information
• Enquire about :
– Diet history…. Likings, time, portion, proportion
etc
– Food habits…. Veg / Non Veg, 2 meals/day, 3
meals/day
– Daily activity… Sedentary, active, vigorous etc
– Socio economical status.. Lower / effluent,
– Cultural practices… type of preparations etc
– Religious practices etc….
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Step 2: Calorie calculation
• Determine ideal / desirable body weight:
• Calculate IBW( ideal body weight) as
– Females: BMI of 21 ( 21 x Height in metersquare)
– Males: BMI of 23 (23 x Height in metersquare)
• Calculate calorie requirement:
– IBW multiplied by 30 / 35 / 40 calorie based on
activity as mild / moderate / rigorous.
– If weight loss is desired, reduce 500 calorie
– If weight gain is desired, add 500 calorie
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• Patient on OHA like:
– Metormin
– Alphaglucosidase inhibitor
– Glitazones
– DPP4 inhibitor
• Patient on OHA like:
– Sulphonyl ureas and its
combination
– Secreatogouges and its
combination
• Patient on
– Basal insulin only or
– Insulins with or without OHA
• Insulin schedule:
– 30:70 twice
– 50:50 twice
– MSI
• Other things to consider:
– Low sodium diet, in gm
– Protiens in gm
– Renal diet etc,
– Low uric acid diet
– Low cholesterol diet
– Renal stone diet etc
Step 3: Calorie distribution
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Important tips on calorie distribution
in Insulin treated patients:
• Patients on 2 premixed insulin doses:
– Plan diet consistent in carbohydrates in all meals
• Patients on MSI
• Patients on Insulin Pump
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Step 4:Macro nutrient Quantity
• Determine distribution of CHO, Fat and proteins: eg 1800 calorie diet plan:
– CHO : 60-65% of 1800 calorie = 270 – 292 gm
– Protien : 10-15% of 1800 calorie = 45 – 68 gm
– Fat : 20-25% of 1800 calorie = 40-50 gm
• CHO:
– Complex CHO is better than simple CHO as absorption is slower,
– Amount of CHO in each meal to be remain same
• Protein intake:
– 1gm/kg body weight,
– Cereals, pulses, nuts, milk and its products, Non veg….
• Fat intake:
– 7-10% SFA
– < 10 % PUFA
– 10-15 % MUFA
• Dietary fibres:
– Delay digestion and absorption , may help in reducing sugars and lipids
– Recommended intake 25-28 gm / 1000 K cal. 10drjoozer@gmail.com

Step 5: Menu / Diet chart
• Translate in terms of food
• Use of exchange lists
– Gives information on nutrient content
– Provides variety in diet by giving alternatives
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Individualised diet planning: sample
Break Fast:
Milk 100 cc
Cereal preparation from 75 gm
cereal ( eg: 3 idlis / chapatis)
Mid morning:
Fruit
Lime juice without sugars
Lunch:
250 gm cooked rice / 3 chapatis
Meat / Fish / Paneer
Vegetables
Curd
Dal or Sambhar
Tea time:
Milk 100 cc
Whole gram or pulse 15 gm
Dinner:
250 gm cooked rice or 3 chapatis
Meal / Fish / Dal
Vegetable
Curd
Bed time:
Milk 200 cc
Oil for cooking 3-4 teaspoons /day
Salt to be adjusted as per need.

General modifications: pre printed
informations:
• Reduce intake of simple sugars, Honey, Sucrose etc
• Avoid fried foods: chips, junk food
• Reduce oil intake, reduce visible fat intake
• Increase use of vegetables: 400 gm / day
• Ensure adequate fibres intake :35 – 40 gm /day
• Eat regular meals
• Prefer 4 to 6 small meals
• Regular food and exercise
• Balanced meal to ensure adequate vitamins and
minerals

Special situation: Nephropathy
• Depending on kidney fuctions:
– Salt / fluid restrictions
– Calorie as for others with Diabetes
– Protein 0.6-0.8 gm / kg IBW
– Fat: less than 30 % of total calorie, preferably 20-
25%
– CHO: to make up rest of the calories , preferably
complex CHO

Other nutrition recommendations:
• Non nutritive sweeteners are safe when compared within the
acceptable daily intake levels by FDA (A).
• If Diabetic adults choose to use alcohol, daily intake to be limited to
moderate amount ( 1 drink / day for females, 2 drinks/ day for
male). (E)
• Supplementations with antioxidants like Vit E and C and carotene,
not advisable, lack of evidence of efficacy and concerns related to
long term safety ( A)
• Benefits from chromium supplementation in people with Diabetes /
Obesity has not been conclusively demonstrated and therefore not
recommended (C)
• Individualised meal planning should include optimization of food
choices to meet recommended dietary allowances (RDA’s)/ dietary
reference intakes (DRI’s) for all micronutrients (E).

USFDA : Artificial sweetener during
pregnancy
S.
No
Name of artificial
sweetener
Safety profile
during pregnancy
Remarks
1. Rebaudioside A Safe GRAS (generally recognised as safe) by
FDA
2 Acesulfame Potassium Safe in moderation
3 Aspartame Safe at moderation Safe during pregnancy and lactation.
Contraindicated L PKU (metabolic
disorder)
4 Sucralose Safe Safe during pregnancy and lactation
5 Saccharin Not safe Risk of bladder cancer.
Crosses placenta and may remain in
fetal tissue, unsafe in pregnancy and
lactation.

Safe dose of sucralose:
• Acceptable daily intake FDA: 5mg / kg / day
• Estimated daily intake : 1.1 mg / kg / day
• Results from over 100 studies, unanimously
indicated a lack of risk associated with
Sucralose intake
• Dose to cause AE: 1500 mg / kg / day
• Highest No adverse effects limit (HNAEL): very
large margin of safety.

Diabetes & Exercise
• Exercise is the most effective Insulin sensitizer
• Exercise is one of the three important arm for
the treatment of Diabetes

Types of Exercise
• Aerobic / Cardio Exercise:
– Generally Isotonic
• Anaerobic exercise / Resistance exercise:
– Generally Isometric

Clinical Implications:
• Even short term (2 Week), regular aerobic exercise in
Type2 DM, results in significant improvement in both
aerobic capacity & whole body Insulin sensitivity.
• Long term endurance training in Diabetic patient
markedly improves whole body Insulin sensitivity and
the expression of key muscle enzymes regulated by
insulin.
• However , to maintain this effect, dedicated regular
and uninterrupted exercise regimen is required.
• Intramyocellular lipid accumulation, which is seen with
insulin resistance in muscle can be decreased by even a
single bout of sustained endurance exercise, in a
manner that depends on both duration of exercise and
workload.

Exercise prescription in DM:
• Before beginning any exercise program,
patient with DM should undergo detailed
evaluation
• A careful medical history, physical examination
should be done focusing on sign and
symptoms of disease affecting the heart,
blood vessels, eyes, kidneys and nervous
system.

Potential adverse effect of exercise:
• Cardiovascular:
– Cardiac dysfunction and arrythmias due to underlying silent IHD
– Excessive increments in blood pressure.
– Post exercise orthostatic hypotension
• Microvascular:
– Retinal haemorrhage
– Increased proteinuria
• Metabolic:
– Worsening of hyperglycemia and ketosis
– Hypoglycemia
• Musculo skeletal and traumatic:
– Foot ulcers
– Accelerated degeneration of joints…. OA etc

Precautions to avoid complication:
• Proper fitting and cushioned footwear
• Avoid exercise in extreme heat and cold
• Daily inspection of feet before and after
exercise
• Avoid exercise when blood sugar control is
poor…… < 100 mg % or > 250 mg %
• Maintain adequate water intake
• Prevent hypoglycemia

Practical considerations: Duration of
exercise?
• Good goal for many should be 4 – 6 times a
week for 30 – 60 minutes at a time.
• Keep in mind, exercise has so many benefits
that any amount is better than no exercise.
• Individualize, as per complications, like
Diabetic foot, neuropathy etc

What is best exercise:
• Walking is considered one of the best choices,
as it is easy, safe, at no cost, less chance of
injuries
• Brisk walking can burn as many calories as
running, and with less chances of fatifue and
injury.

What Guideline say?
• Exercise plays a crucial role in management of Type 2
DM, as per American Diabetes Association and
American College of Sports Medicine. (ADA / ACOSM)
1. For Type 2 DM :
– Atleast 150 minutes / week of moderate to vigorous
aerobic exercise, at least 3 day / week, with more than 2
consecutive days between bout of aerobic activity
– It takes into account the limitations of vigourous exercise
for some DM patients
2. Such Moderate exercise corresponds to approx 40 –
60 % of maximal aerobic capacity, and they
recommend that for most DM patient brisk walking is
a moderate intensity exercise.

3. Resistance training should also be part of
exercise regimen:
– Atleast 2 times / week
– Ideally 3 times a week on non consecutive days
4. Regular use of pedometer is also encouraged to
monitor and record exercise
5. Exercise should be done regularly to have
continued benefits and should include regular
training of varying types.
6. Physicians treating should prescribe exercise as
per individualization
What Guideline say?

What is good exercise?
• Moderate intensity exercise corresponds to
approx 40 – 60 % of maximal aerobic capacity.
• High intensity exercise can be stress inducing
rather than stress reducing ( > 80 % of
maximal aerobic capacity)

Measuring Exercise Intensity:
• Defined by % maximal aerobic capacity or by %
VO2 max ( Estimated by THR )
– Mild : 20 – 30 % of VO2 max
– Moderate : 40 – 60 % of VO2 max
– Vigorous: > 75 % of VO2 max
• VO2 max or maximal aerobic capacity:
– Maximum amount of oxygen that an individual can
utilize during intense or maximal exercise.
– Aerobic exercise intensity is defined by THR calculated
from maximum HR.
– THR is indirectly equivalent to VO2 max

Exercise Intensity for Benefit:
• Example: person aged 40 yrs, HRmax of 180
(220-age):
– 65 % intensity : (220 – 40) x 0.65 = 117 bpm
– 85 % intensity: (220 – 40) x 0.85 = 153 bpm
• Desired HR reached during aerobic exercise
provide the most benefit from a workout.
– DHR during exercise = 220 – 40 x .6

Diabetes and Yoga:
• Few studies claim beneficial effects of Yoga on
Diabetes.
• Possible Mechanism of its action:
– Simple Exercise Effect
– Inculcating Discipline in Life and Diet
– Cuts down stress and strain
• Claim that Yoga may cure Diabetes is over
exaggerated.

Diet and exercise in diabetes

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Diet and exercise in diabetes