Sakina Rangwala Mumbai India

Management of Type 2 Diabetes Mellitus- Beginner’s guide

-Sakina Shoeb RANGWALA

Due to an epidemic change observed in our environment, diabetes has become very common and certain after a respective age. When conditions become common , its management becomes crucial for well being.Here lets see an effective, easy and consistent management theory for patients aiming to give them optimum quality of life.

WHAT IS TY2 DM ?

A stressful conditions in our body where our cells can’t use blood glucose (sugar) to meet the energy needs. This only happens when our cells become insensitive to a pancreatic hormone insulin thereby resulting in high blood glucose level. In type 2 , pancreas produces insulin, but our cells cant use it effectively.

This is an adult onset Diabetes mellitus, and occurs due to the defect of pancreas producing versatile amounts according to the body homeostasis.

To treat type 2 – Oral hypoglycemic agents like- sulfonylureas, biguanides metformin, thiazolidinediomes, alpha glucosidase inhibitors , are given after food consumption to increase –

1)the liver uptake of glucose

2) increase insulin sensitivity

Unmanaged TY 2DM can cause long term micro and macro complications which include- nephropathy, neuropathy, retinopathy.

PRINCIPLES &GUIDELINES

CONSISTENCY

• • Normal diet

• • The consistency of the food will influence the gastric emptying, hence the food should be such that there is slow gastric emptying in consideration of giving oral hypoglycemic agents.

FREQUENCY :The interval gap between each of the meals should be at least of2-3 hours.

Low GI foods and high fibers foods will keep her feel full for more time . As she is pregnant small frequent meal which is nutriently dense for balance glucose level in blood.

Frequency should work hand in hand with insulin regime or else patient can go in hyper or hypoglycemia.

ENERGY

• Thus her actual energy requirements are kcals/day plus 250 kcals increment is given to support all physiological functions according with the increase in BMR.. Due to her pregnancy, weight increases near 5-6 kg - 2ndtrimester of pregnancy , maintenance diet after delivery period is recommended so that she does not put on weight .This will help in bringing her blood glucose to normal, without affecting the fetal development.

PROTEIN

• The protein recommendations of 1.2- 1.3 g/kg /day is suggested for supporting optimum growth of maternal tissue, placenta, uterus, fetus etc.

• The good quality protein like- egg, fish , paneer, soy, milk is essential since it helps in lowering GI of the food which will help to maintain proper glucose level plus development of fetus.:

• Also this protein will help in maintaining body tissues by balancing wear and tear of the body and recovering the losses.

• High biological value foods like milk and its products should be consumed.

• Complementary proteins and cereal-pulse combination will also help in improving protein quality. Eg- dal rice, idli sambar, paneer paratha.

FATS-

• Of the total fat recommended. 50% should be invisible fat.

• Fat quality needs to be maintained which includes maintaining the ratio of SFA: MUFA: PUFA of 1:1.5:1: Omega 3 and Omega 6 being very essential fatty acids needs to be consumed by her to carry out varied functions. The ratio of omega 6: omega 3 of 5:1 should be maintained, Omega 3 rich foods should be consumed since it has varied functions like lowering B.P. inflammation and platelet aggregation and its sources are very less compared to Omega 6. The need of omega 3 increases during pregnancy for cognitive, motor development of fetus, and to prevent neural disorders in infant.

• Omega 3 rich foods like – flaxseed, wall-nut , fish is excellent source of EPA..

• Good quality of fat is very important as she fat is reserved and stored in body for lactation period.

CARBOHYDRATE

• The carbohydrate recommendations of 60% of total calories is suggested.

• Carbohydrate should be taken care of as it can increase blood sugar levels and can also get converted to fat and get stored in our body.

• She should choose fiber rich polysaccharides as it will take more time for its digestion and absorption than refined carbohydrates like white bread, chocolates, maida .

• Highly cooked foods, pureed foods, fruit juice increases GI and GL. It should be avoided or accompanied by salad.

FIBER-

• 25-30 gms of fiber should be consumed. Soluble and Insoluble fiber both should be present in his diet. and will prevent constipation and gastric disturbance plus increase good bacterias in gut.40 % of total fiber should be soluble fiber which prevents glucose spike in blood – okra, meethi seeds, isabgol, banana, oats ( beta glucan) consumption with meals.

SUGARS-

• Sugars should he avoided if possible as it increases the blood glucose drastically.If taken should be distributed along all meals with addition of soluble fibers or can eat isabgol after dessert.

• Sweeteners like sucralose or stevia can be consumed which are non-nutrient based compounds as they do not give any calories and hence do not affect the blood glucose levels. As she is pregnant limited use of sweetners is avoided as it may cause carcinogenic effect. Should be taken only after proper dieticians prescription.

MICRONUTRIENTS

Vitamin A - Vitamin A adequacy is essential for vision in dim light; since its an anti-infective vitamin. it helps in maintaining integrity of epithelial tissues.

Retinol- 800mcg/d

Beta carotene-6400mcg/d

SOURCES: Orange and yellow foods

Vitamin D - Vitamin D is involved in absorption of calcium which is essential to maintain maternal bone health and to prevent osteoporosis later in life.. Dairy products and enough exposure to sunlight helps. It is anti inflammatory also.

Vitamin E - Vitamin E approx. 600 milligrams hould be consumed daily to reduce complications because it has anti- inflammatory effects and antioxidant properties. Since diabetes is-inflammatory diseases. vitamin E should be consumed through dict. Consume enough nuts and green leafy vegetables.

Vitamin C - Vitamin C also should be included in his diet as it has antioxidant properties and is very important for body building ie collagen formation. Thus consumption of 150-200 mg will be helpful. Consume citrus fruits germinated pulses and some vegetables like cabbage, drumstick leaves. fenugreek leaves, capsicum., cauliflower.

Vitamin B - complex- BI. B2 and B3 is essential for metabolism of energy. Biotin 9-16 milligrams /day improves nerve function, and DNA synthesis. B6 inhibits glycation and hence should be consumed. B9 and B12 are involved in cell division and hence RDA should be met.

B1 - +0.2 mg/d

B2- +0.3 mg/d

B3- +2 mg/d

B12 supplements is essential as metformin causes it's deficiency.

Calcium - Calcium is very essential as it reduces insulin resistance and also for maintaining bone health and also for contraction of muscles. Hence 1000-1500 milligrams /day of consumption will be helpful.

Sources: milk and dairy products.

Optimum Ca is required as fetus draws Ca from maternal stores , if deficient osteoclasting effect may occur leading to fragile bone prone to multiple fractures.

Potassium - potassium rich foods should be consumed by him since it increases the peripheral by arteriolar dilation.

Magnesium- magnesium consumption of 400 magnesium consumption of 400 mg/day/day will help to increase insulin action. Consume enough green leafy vegetables. Manages insulin resistance.

Chromium- chromium helps in injected insulin to work better. Adequacy is must. It is a glucose tolerant factor , helps in glucose sensitivity

Cr- 200mcg/d

Supplement- picolinate Cr

Zinc- Zine helps in decreasing oxidative stress. Zine and selenium consumption is necessary for as it has antioxidant properties.

Cinnamon- since it helps in uptake of glucose, helps in glycogen synthesis its consumption is very effective. .

Suggested-2-4 g/day

Cloves-Cloves act like insulin in hepatocytes, thus prove to have anti-hyperglycemic effects. Intake

recommended 2 g /kg

Cumin-seeds- Cumin seeds have hypoglycemic effects and also reduces glycated hemoglobin levels. Best effects are seen as a mixture of cumin seeds along with mustard seeds, coriander seeds, and ginger and curry leaves

Curry leaves- Curry leaves have properties of lowering blood glucose

Methi seeds- Methi seeds have varied properties like anti-inflammatory properties, enhancing peripheral insulin action and antioxidant properties.

Garlic- Garlic increases hepatic metabolism, increases insulin release and also has anti-hyperglycemic effects. Garlic will also help in lowering blood pressure.

Ginger- Ginger helps in reducing diabetic complication, and also has hypoglycemic effect.

Mustard seeds- Mustard seeds being the rich source of magnesium helps in regulating blood glucose levels

Sesame seeds- Til helps in regulating blood glucose and also reduces glycosylated hemoglobin.

Turmeric- Turmeric has antioxidant properties and also ani-inflammatory properties.

Flaxseeds- it should be consumed since it increases insulin receptors and also affinity for insulin receptors.

Glycemic index and Glycemic load

• High fibre-rich polysaccharides have various benefits for soluble and insoluble fibers

like increased satiety and lowering of glycemic index and Load also very important to keep in mind insulin regime.

• It is important to take into account the glycemic load and index for diabetics (DM)

especially because it affects the function of insulin.

Low GI foods include:

Beans

Tomatoes

Dark green leafy vegetables like spinach

Fish high in omega 3 fatty acids like salmon

Citrus fruits

Whole grain cereals and pulses

Sweet potato(lots of fibre with starch)

Nuts

Berries

Fat free milk like yogurt

Moderate GI foods include:Whole wheat,Brown, White or basmati rice

High GI foods include: White bread, Corn flakes, Pumpkin, Puffed rice ,popcorn ,white rice

• Gl and GL can be taken care of by suggesting mixed meals i.e. each meal should have fats, proteins as well as carbohydrates.

• Retrogradation of starches by cooking - cooling- chilling overnight and then using

starch rich foods like rice, potato etc. Also lowers GI

RECOMMENDATIONS

AS per your health status you are allowed to eat following foods-

• Fat whole grains like wheat, brown rice, wild rice,, barley etc

• Eat oats combined with vegetables

• Choose whole wheat bread.

• Eat non-veg (1 serving) but limited consumption of red meat.

• Eat all kinds of pulses, Dals and beans.

• Eat sprouts

· Not to miss any dose of insulin and following decided schedules is very important for maternal n fetal health as to prevent complications during delivery.

• Soybean, soy chunks should be consumed for protein by vegetarians.

• Consume meals that have cereal-pulse combination.

• Drink milk everyday.

• Curd, buttermilk. Paneer should be consumed

• Choose dark green leafy vegetables, red yellow colored vegetables.

• Try new combinations of vegetables.

• Consume a bowl of salad at least one time in a day.

• Eat fruits as recommended.

• Consume fruits 2-3 times a day as suggested – in between the meals.

• Recommended amounts of nuts can be consumed daily especially wall-nuts to get your superhero omega 3.

• Preferably among all nuts and oilseeds. choose almonds, walnuts. flax seeds, sesame seeds, garden cress seeds

• Recommended amounts of oil and fats should be used while cooking.

• Choose mustard oil, olive oil, rice bran oil.

• Meet S.F.A: M.U.F.A PUF.A ratio and n3 &n6 ratio.

• Choose sugar free products.

• Clean, wash fruits and vegetables before eating or cooking.

• Practice hygiene and safety procedures while preparing and cooking food.

• Eat meals on time.

• Sleep for at least 8-9 hours as recommended.

• Before any , yoga ,physical work,, carbohydrates rich foods should be consumed.

• Do yoga to strengthen pelvic muscle, preparing for delivery.

• . Glucometer should be always carried by the person to measure blood glucose levels

• Use supplements if not able to meet vitamins and mineral requirements, but by prescription.

As per your health status, please avoid the following foods-

• Avoid refined carbohydrates like, processed wheat flour, white rice.

• Avoid eating white bread, sweetened / flavored bread.

• Do not directly cook the pulses, beans without soaking.

• Reduce the amount of cheese, paneer

• Do not eat completely cooked vegetables.

• Reduce eating starchy vegetables like potatoes, raw banana, yam, sweet potato. As it increases glycemic load .

• Avoid consuming processed foods like jams, jellies, pickles,etc.

• Reduce the amount of ready to cook and ready to eat cereals.

• Reduce consuming Kari biscuits, cream biscuits, plain biscuits

• Avoid eating sweet fast foods. Like desserts ., rasgulla can be eaten by squeezing all the sugar syrup, small quantities of ice cream.

• Do not eat cakes. sweets. pastries, chocolates, juices.

• Avoid consuming alcohol and smoking it will severely effect fetus in womb.

• Avoid carbonated drinks

• Avoid waking till late very often, avoid stress . Communicate with family members , elders etc, enjoy your pregnancy period.

CONCLUSION

Smart management is the only key to sustainable wellbeing. With the diet and lifestyle, stress , social management and maintenance also play a key role in ones body. Stay fit and smile wide.