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Sweeteners

In document Quality of Life (Page 66-71)

2.10 Diet and diabetes

2.10.2 Requirements from the food groups

2.10.2.3 Sweeteners

Substantial evidence from clinical studies demonstrates that dietary sucrose does not increase glycaemia more than isocaloric amounts of starch.76 Thus, intake of sucrose and sucrose-containing foods by people with DM does not need to be restricted because of concern about aggravating hyperglycaemia. Sucrose can be substituted for other carbohydrate sources in the meal plan or, if added to the meal plan, adequately covered with insulin or another glucose-lowering medication.76 Additionally, intake of other nutrients ingested with sucrose, such as fat, need to be taken into account, and care should be taken to avoid excess energy intake.In individuals with DM, fructose produces a lower postprandial glucose response when it replaces sucrose or starch in the diet; however, this benefit is tempered by concern that fructose may adversely affect plasma lipids.76 Therefore, the use of added fructose as a sweetening agent in the diabetic diet is not recommended. There is, however, no reason to recommend that people with DM avoid naturally occurring fructose in fruits, vegetables, and other foods. Fructose from these sources usually accounts for only 3–4% of energy intake. Reduced calorie sweeteners approved by the US FDA include sugar alcohols (polyols) such as erythritol, isomalt, lactitol, maltitol, mannitol, sorbitol, xylitol, tagatose, and hydrogenated starch hydrolysates.76 Examples of NAFDAC approved reduced caloric sweeteners are saccharin and cyclamates.84

2.10.2.4 PROTEIN IN DIABETES MELLITUS MANAGEMENT

Protein should constitute 15–25% of the diet. About 1g of protein provides 4 kcal of energy.72 Good-quality protein sources are defined as having high PDCAAS (protein digestibility–corrected amino acid scoring pattern) scores and provide all nine indispensable amino acids. Examples are meat, poultry, fish, eggs, milk, cheese, and soy. Sources not in the “good” category include cereals,

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grains, nuts, and vegetables.76 The dietary intake of protein for individuals with DM is similar to that of the general public and usually does not exceed 20% of energy intake.76 A number of studies in healthy individuals and in individuals with T2DM have demonstrated that glucose produced from ingested protein does not increase plasma glucose concentration but does produce increases in serum insulin responses. Small, short-term studies in DM suggest that diets with protein content

>20% of total energy reduce glucose and insulin concentrations, reduce appetite, and increase satiety.76

2.10.2.5 DIETARY FAT AND CHOLESTEROL IN DIABETES MELLITUS MANAGEMENT

Fat should constitute 15–25% of the diet. About 1 g of dietary fat provides 9 kcal of energy.72 Saturated, mono-unsaturated, and polyunsaturated fat should each make up one-third of the dietary fat.76 The primary goal with respect to dietary fat in individuals with DM is to limit saturated fatty acids, trans fatty acids, and cholesterol intakes so as to reduce risk for CVD. Saturated and trans fatty acids are the principal dietary determinants of plasma LDL cholesterol. In nondiabetic individuals, reducing saturated and trans fatty acids and cholesterol intakes decreases plasma total and LDL cholesterol.76

Reducing saturated fatty acids may also reduce HDL cholesterol. Importantly, the ratio of LDL cholesterol to HDL cholesterol is not adversely affected. Studies in individuals with DM demonstrating the effects of specific percentages of dietary saturated and trans fatty acids and specific amounts of dietary cholesterol on plasma lipids are not available.76 Therefore, because of a lack of specific information, it is recommended that the dietary goals for individuals with DM be the same as for individuals with preexisting CVD, since the two groups appear to have equivalent cardiovascular risk. Thus, saturated fatty acids <7% of total energy, minimal intake of

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trans fatty acids, and cholesterol intake <200 mg daily are recommended.76 In metabolic studies in which energy intake and weight are held constant, diets low in saturated fatty acids and high in either carbohydrate or cis-monounsaturated fatty acids lowered plasma LDL cholesterol equivalently. Diets high in polyunsaturated fatty acids appear to have effects similar to monounsaturated fatty acids on plasma lipid concentrations.76 A modified Mediterranean diet, in which polyunsaturated fatty acids were substituted for monounsaturated fatty acids, reduced overall mortality in elderly Europeans by 7%. Very-long-chain n-3 polyunsaturated fatty acid supplements have been shown to lower plasma triglyceride levels in individuals with T2DM who are hypertriglyceridaemic. Although the accompanying small rise in plasma LDL cholesterol is of concern, an increase in HDL cholesterol may offset this concern. Consumption of ω-3 fatty acids from fish or from supplements has been shown to reduce adverse CVD outcomes, but the evidence for α-linolenic acid is sparse and inconclusive.76 In addition to providing n-3 fatty acids, fish frequently displace high–saturated fat–containing foods from the diet. Two or more servings of fish per week (with the exception of commercially fried fish filets) can be recommended. Plant sterol and stanol esters block the intestinal absorption of dietary and biliary cholesterol. In the general public and in individuals with T2DM, intake of ∼2 g/day plant sterols and stanols has been shown to lower plasma total and LDL cholesterol.76

2.10.2.6 SODIUM:

2400 mg/day is recommended (One level teaspoonful = 2000 mg).72 People with DM are frequently hypertensive.77 Modest restriction of sodium intake can be beneficial to most diabetics.

On the other hand, severe sodium restriction may be harmful in poorly controlled DM when there is postural hypertension and fluid imbalance.77

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2.10.2.7 ALCOHOL IN DIABETES MELLITUS MANAGEMENT

Advice is similar to those without DM, i.e. up to 3 units/day (males) and 2 units/day (females).72 If weight loss is needed, alcohol should be restricted.72 Abstention from alcohol should be advised for people with a history of alcohol abuse or dependence, women during pregnancy, and people with medical problems such as liver disease, pancreatitis, advanced neuropathy, or severe hypertriglyceridaemia.76 If individuals choose to use alcohol, intake should be limited to a moderate amount (less than one drink per day for adult women and less than two drinks per day for adult men). Moderate amounts of alcohol, when ingested with food, have minimal acute effects on plasma glucose and serum insulin concentrations. However, carbohydrate congested with alcohol may raise blood glucose.76 For individuals using insulin or insulin secretagogues, alcohol should be consumed with food to avoid hypoglycaemia. Evening consumption of alcohol may increase the risk of nocturnal and fasting hypoglycaemia, particularly in individuals with T1DM.

Occasional use of alcoholic beverages should be considered an addition to the regular meal plan, and no food should be omitted.76 Excessive amounts of alcohol (three or more drinks per day), on a consistent basis, contributes to hyperglycaemia. In individuals with DM, light to moderate alcohol intake (one to two drinks per day; 15–30 g alcohol) is associated with a decreased risk of CVD. The reduction in CVD does not appear to be due to an increase in plasma HDL cholesterol.

The type of alcohol-containing beverage consumed does not appear to make a difference.76

2.10.2.8 OPTIMAL MIX OF MACRONUTRIENTS

Although numerous studies have attempted to identify the optimal mix of macronutrients for the diabetic diet, it is unlikely that one such combination of macronutrients exists.76 The best mix of

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carbohydrate, protein, and fat appears to vary depending on individual circumstances. It must be clearly recognized that regardless of the macronutrient mix, total caloric intake must be appropriate to weight management goals. Further, individualization of the macronutrient composition will depend on the metabolic status of the patient (e.g., lipid profile).76

2.10.2.9 MICRONUTRIENTS IN DIABETES MELLITUS MANAGEMENT

Uncontrolled DM is often associated with micronutrient deficiencies. Individuals with DM should be aware of the importance of acquiring daily vitamin and mineral requirements from natural food sources and a balanced diet. Health care providers should focus on nutrition counselling rather than micronutrient supplementation in order to reach metabolic control of their patients.76 Research including long-term trials is needed to assess the safety and potentially beneficial role of chromium, magnesium, and antioxidant supplements and other complementary therapies in the management of T2DM. In select groups such as the elderly, pregnant or lactating women, strict vegetarians, or those on calorie-restricted diets, a multivitamin supplement may be needed.76 2.10.2.10 ANTIOXIDANTS IN DIABETES MELLITUS MANAGEMENT

Since DM may be a state of increased oxidative stress, there has been interest in antioxidant therapy. Unfortunately, there are no studies examining the effects of dietary intervention on circulating levels of antioxidants and inflammatory biomarkers in diabetic volunteers. The few small clinical studies involving DM and functional foods thought to have high antioxidant potential (e.g. tea, cocoa, and coffee) are inconclusive.76 Clinical trial data not only indicate the lack of benefit with respect to glycaemic control and progression of complications but also provide evidence of the potential harm of vitamin E, carotene, and other antioxidant supplements. In

In document Quality of Life (Page 66-71)