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Diet and diabetes: theory and practice for care providers

Article · April 2007

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 Original Review

Diet and diabetes: theory and practice

for care providers
S Chinenye, C N Unachukwu, and A Hart

Introduction Table 1 The WHO classification of weight status

Diabetes, particularly type 2 diabetes is one of the fast- WHO classification BMI (kg/m2)
est growing public health problems in the world. It has
been estimated that the number of diabetes sufferers in Underweight <18.5
the world will double from the current value of about Normal range 18.5 – 24.9
190 million to 325 million during the next 25 years.1 Class I overweight 25.0 – 29.9
The amount and type of food consumed is a funda-
Class IIa obese 30.0 – 34.9
mental determinant of human health. Diet is one of the
Class IIb obese 35.0 – 39.9
major factors now linked to a wide range of diseases
Class III obese ≥40.00
including diabetes. Diet constitutes a crucial aspect of
the overall management of diabetes which may involve
diet alone, diet with oral hypoglycaemic drugs or diet WHO also favours the use of waist circumference (WC)
with insulin. Diet is individualised depending on age, alone rather than waist:hip ratio (WHR) to assess ab-
weight, occupation, etc. dominal fat, because it is a simpler measure and closely
The dietary guidelines as used in this review are sets correlates with disease risk.2
of advisory statements that give quick dietary advice A recent evaluation of the pattern of diabetes in Rivers
for the management of the diabetic population in order State, Nigeria, under the auspices of the local Diabetes
to promote overall nutritional well-being, glycaemic Association revealed that the type 1 diabetic patients
control, and prevent or ameliorate diabetes-related were relatively underweight at diagnosis with a mean
complications. BMI±SD of 18.3±2.3 and the type 2 patients were rela-
tively overweight, especially the females (BMI 27.7±5.8,
Objectives of dietary treatment of diabetes see Table 2).
The aims of dietary treatment of diabetes are: The usually recommended daily intake for the non-
• To achieve optimal blood glucose concentrations. obese diabetic patient is between 1500 and 2500 kcalories
• To achieve optimal blood lipid concentrations. per day, the average allowance being 2000 kcalories per
• To provide appropriate energy for reasonable weight, day.3 The recommendation for the overweight diabetic
normal growth and development, including during patient is between 800 and 1500 kcalories per day, while
pregnancy and lactation. the underweight (including growing children and ado-
• To prevent, delay, and treat diabetes-related complica- lescents) should be allowed at least 2500 kcalories/day
tions. and above.3
• To improve health through balanced nutrition.
Peculiar tropical problems with dietary
Anthropometry and daily calorie intake prescriptions
The World Health Organization (WHO) has accepted a Some socio-economic factors distinguish the problems of
classification2 of weight status according to body mass dietary management of diabetes in a tropical developing
index (BMI) and defines overweight as a BMI ≥25 kg/m2 country from the experience in the industrialised world.
and obesity as BMI ≥30 (see Table 1). These BMI values Illiteracy rates can be as high as 75–85% among Nigerian
are independent of age and gender. For regional obesity, diabetic patients,4,5 hence they depend on their relatives
to read the conventional diet sheets.
Among the few who are educated, the level of medical
Dr S Chinenye and Dr C N Unachukwu, Lecturers/ literacy is low.5 There is a lack of registered/practising
Consultant Physicians, Department of Medicine, dieticians at the primary and secondary healthcare lev-
University of Port Harcourt Teaching Hospital; and
Dr A Hart, Senior Lecturer/Dietician, Department of els, coupled with an absence of national standardised
Food Science & Technology, Rivers State University measures and dietary formulae. Attempts to adhere to
of Science & Technology, Nkpolu Oroworukwo, Port the conventional food measurements in order to comply
Harcourt, Nigeria. Correspondence to: with prescriptions of the so-called ‘diabetic diet’ usu-
Dr S Chinenye, Co-ordinator, Diabetes Association ally result in unnecessary restrictions, overindulgence,
of Nigeria, Rivers State Chapter, PO Box 8186, Port or monotonous consumption of certain food items, e.g.
Harcourt, Nigeria. Email: [email protected]
unripe plantain and/or beans. This is a consequence of

May 2007 Mera: Diabetes International 9

 Review Article

Table 2 Demographic and glycaemic parameters of newly diagnosed diabetic patients (n = means±SD)

Parameter Type 1 Type 2 Other specific types Gestational

diabetes diabetes diabetes

Age groups (yrs) 0–9 4 (0.5%) – – –

10–19 13 (1.6%) 7 (0.8%) 7 (0.8%) –
20–29 8 (1.0%) 23 (2.8%) 3 (0.4%) 7 (0.8%)
30–39 – 116 (2.8%) – 8 (1.0%)
40–49 – 240 (29.0%) – –
50–59 – 206 (24.8%) – –
60–69 – 150 (18.1%) – –
70–79 – 38 (4.6%) – –
80+ – – – –
Total number (%) 25 (3%) 780 (94%) 10 (1.2%) 15 (1.8%)
Mean age ±SD 20±7.0 48±13.0 21.0±7.6 32±5.0
(at diagnosis)
Gender ratio (M:F) 1:1 1:1.4 2.3:1 All female
BMI ±SD 18.3±2.3 27.4±5.5 17.5±3.1 27.8±5.3
BMI (males) 17.5±2.0 24.9±4.3 16.9±2.1 –
BMI (females) 19.1±2.8 27.7±5.8 18.1±2.6 27.8±5.3
Age (males) 14.0±5.0 47±13.0 19.0±6.1 –
Age (females) 24.0±8.0 48±14.0 23.0±7.2 As above

illiteracy, poverty, and cultural misconceptions about chicken, etc.) and salt are restricted for those with
the role of diet in the management of diabetes.4 This is diabetic nephropathy.
usually the most problematic aspect of diabetes care. 7. The items allowed for free consumption include:8
In view of the above, the authors recommend ‘rule of (a) water, green leafy vegetables, tomatoes, onions,
thumb’ dietary guidelines based on practical experience. cucumber, aubergine, peppers, vegetable salad with-
These could be useful to healthcare givers at the primary out cream.
or secondary levels. (b) Any brand of tea, coffee or drinks that contain
very low or no calories.
General dietary guidelines 8. Cigarette smoking should be avoided by diabetic
Modern dietary management of diabetes essentially patients. Alcohol should be taken only in moderation.
involves modifications of the quality and quantity of 9. For patients too ill to eat solid food, a fluid or semi-
food to be taken by the diabetic patient. The following solid diet should be substituted (pap, soya bean,
guidelines are applicable to diabetes irrespective of type, custard, etc.).
weight status, age, gender, or occupation. 10. Patients treated with insulin or certain oral hypogly-
1. Most of the carbohydrate consumed should be in caemic agents, e.g. sulphonylureas, must be advised
the form of starch (polysaccharides) such as maize, to eat regularly and often to prevent hypoglycaemia
rice, beans, bread, potatoes, yam, cassava, ‘foofoo’, – three meals a day plus suitable snacks in between,
semovita, plantain, ‘amala’, garri, pap, etc. e.g. fresh fruit or two unsweetened biscuits.
2. All refined sugars such as glucose, sucrose, and their 11. Small meals spaced over the day rather than one or
products (soft drinks, malt drinks, sweets, toffees, two big meals, are helpful in avoiding post-prandial
etc.) and honey should be avoided except during peaks in blood sugar.
severe illness or episodes of hypoglycaemia. These 12. The diet should be varied to avoid monotony and
foods contain sugar in a simple form, which is easily provide a wider range of nutrients for healthy living.
absorbed causing rapid rise in blood sugar.
3. Non-nutritive sweeteners, e.g. Canderel, saccharine, Anthropometrics and dietary recommen-
Nutrasweet, aspartame are suitable sugar substitutes dations
for diabetic subjects. The broad principle of daily energy recommendation
4. Animal fat such as butter, lard, egg yolk, pork, and is based on maintaining the ideal body weight for the
other foods high in saturated fatty acids and cholesterol height of each individual.6 The dietary regimen is indi-
should be reduced to a minimum and replaced with vidualised and should be tailored to nutritional needs,
polyunsaturated fats6 such as vegetable oils. abilities, dietary habits, likes and dislikes, or idiosyn-
5. Salt should be reduced whether hypertensive or not. crasies of each patient. However, faulty dietary habits
6. Protein (fish, meat, beans, crab, crayfish, soyabean, should be corrected.

10 Mera: Diabetes International May 2007

 Original Review

Underweight (BMI<18.5 kg/m2) A ‘rule of thumb’ here is that through ‘systematic self-
The goal here is to gain or regain weight. To gain weight management education’ offered by the healthcare team,
the patient must take in more calories than needed to diabetic patients can ‘eye-ball’ their foods to determine
meet the body’s physical activity requirements. Emphasis portion size. Effective education however involves rein-
should be on a balanced diet, keeping to his or her forcement and patience but it is usually rewarding.
favourite foods, regular meals, and increasing the ‘serving
size’ (otherwise called portion control)7 to about twice Normal weight (BMI 18.5–24.9 kg/m2)
what the patient is already consuming. Weight gain or The fundamental principle behind maintenance of body
regain is gradual and the patient should be regularly weight is the energy balance. This group should be en-
reviewed (at 2 to 4-week intervals) and further increase couraged to maintain their current weight by:
in ‘serving size’ made when deemed necessary. Insulin • maintaining current ‘serving sizes’
(an anabolic hormone) and the sulphonylureas enhance • eating about the same amount of food each day
weight gain and their use should be considered in • eating at about the same times each day
underweight diabetic patients. • taking their drugs at the same times each day
• exercising at the same times each day.
Overweight (BMI>25 kg/m2) These patients should also endeavour to choose their
The aim here is to reduce weight while optimising drug daily foods from starches, vegetables, fruits, and protein,
therapy. Overweight/obesity occurs when energy intake while limiting the amount of fats.
has exceeded energy expenditure over a long period
of time, thus weight reduction must be gradual over a Conclusions
period of time – the target should be about 1.0–1.5 kg Diet is an important aspect in the management of a dia-
loss every 1 to 2 weeks. betic patient. Unfortunately many health facilities in the
We have observed obesity ‘unawareness’ among our tropics do not have the services of a dietician. It is hoped
diabetic patients (mainly type 2 diabetics) and this point that the dietetic manpower needs of tropical countries
must be stressed during patient education. will be met in the near future. Until then, the diabetic
In limiting the number of calories consumed per day, the healthcare provider and the patient should understand
patient does not need to abstain from his/her favourite the basic dietary needs of the patient using a ‘rule of
foods; what is needed is to know how much to cut back on thumb’ approach. Where a dietician is available, regular
the ‘serving size’ (portion control).7 The target initially visits to both the physician and the dietician should be
is to cut down to half the previous serving size per meal the mainstay of management.
with a monthly review and subsequent reductions when
deemed necessary. The ‘serving size’ reduction should References
affect particularly the complex carbohydrates, which 1. World Health Organization. Definition, Diagnosis And Classifica-
constitute the main staple foods in the tropics (see point tion Of Diabetes Mellitus And Its Complications. Report of WHO
consultation. Part 1. Geneva: WHO, 1999.
1 in the general dietary guidelines above). 2. Prevention And Management Of The Global Epidemic Of Obesity.
Many of our type 2 dietary patients find portion control Report of the WHO consultation on obesity, Geneva: WHO,
an important aspect of the solution to losing weight. By 1998.
3. Otuyelu F. Diabetic diet for the Nigerian. Niger Med Pract 1982;
monitoring the serving size of the foods and combining 3: 48–51.
it with regular exercise and drugs (especially metformin), 4. Famuyiwa OO. Problems and challenges in the practice of en-
patients can enjoy a wider variety of meals including docrinology in a developing country-part II: Diabetes mellitus.
Nigerian Medical Prectitioner 1990; 20: 47–52.
their favourite foods and ethnic dishes, and still lose 5. Fadupin GT, Keshinro OO. Factors influencincing dietary compli-
weight. Portion control can also help overcome the big- ance and glycaemic control in adult diabetic patients in Nigeria.
Diabetes Int 2001; 11: 59–61.
gest challenge, which is maintaining the new healthy 6. Fadupin GT, Keshinro OO, Sule ON. Dietary recommendations:
weight. When overweight diabetic patients shed some example of advice given to diabetic patients in Nigeria. Diabetes
weight by trimming down ‘serving sizes’ and calories, International 2000; 10: 68–70.
7. American Diabetes Association. Diabetes e-newsletter. Sat.2
insulin sensitivity improves, thereby optimising drug August 2003. Portion control or how much food is enough.
therapy. [email protected].

May 2007 Mera: Diabetes International 11

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