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we all are clear regarding importance of dietary advice to the diabetic patients, most of us know the reduction of refined sugars in the diet along with reduced intake of fats is the basic principle in management of diabetes along with caloric intake adjustments as per daily physical activity( consumption ) . we use so many ways to communicate the patients so that it becomes convenient for them to learn, remember and abide by the dietary precautions.problems observed in effective achievement of the goal are

1. poor under standing of dietary aspects of diabetes by the doctors.

2. lack of communication skills on part of doctors

3. lack of knowledge regarding composition of different foods and there caloric values by the doctors.

4. lack of adequate time for counselling

5. illiterate patients

6. old age patients or people with poor memory to learn in few minutes about dos and donts 

7. poor compliance by the patients.

to make it effective we have to prepare in this discussion clear cut list of dos and donts which we may practice to give in a written in the form of a card  to all patients and we have to include only common foods as per patients routine with special consideration to uneducated and illiterate patients as they are more prone to have poor understanding than elite class. moreover this will enhance our knowledge and communication skills along with clear headedness in the subject. remember we cannot include everything in the list we have to include only those things which are commonly used at home as diet and having major affect on blood sugar levels. more over we have to ask few questions to the patients to maintain and improve compliance. i start with my general practice during opd follow ups

which include

1. i always ask

a. how is sugar control

b, do u know what r the things to avoid in diet

c. what is your routine diet mean breakfast, lunch, dinner and common things u eat

d. are u following the dietary precautions and how many times in a week u don't follow. if cannot recollect next time please keep a note of time and date when you are not able to follow and bring that to me  so that i may better judge your compliance. (near relative may give the help and this is probably possible with educated people only but will have a mild impact on others as well)

2. i advise to

a. walk as much as possible

b. reduce weight to obese patients only

3. in the diet i advise to avoid

a.  ghee, butter. egg yolk, paratha, fried items in ghee

b. sugar. gur. and all kind of sweets, burgers, bread. naan 

c. in vegetables potato

d. in meat beef 

e. never eat up to your fill.

i invite all my colleagues now to add on to the discussion your view points, i specially invite madam sujata udeshi to give expert opinion being nutritionist

c.  

 

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Very healthy topic ! Somewhere we can't spare time to educate patient whether s/he may be diabetic / hypertensive / renal .

Diabetes all over the world has grown multi folds and so has its understanding about management which has a direct impact on dietary management. So I wish to go step by step. By the end you all will know why we need a talior made approach than a common prescription to all diabetics. 

Here I am limiting to Type 2 Diabetes. Even all type 2 diabetics are not same. If there is a family history then probably the Beta cells are not secreting enough insulin (So keep a check on fasting and pp insulin to manage carbohydrate load). If high sugars is due to insulin resistance then most of the time very low calorie diet will do wonders.

Diabetes or raised blood sugars is a consequence of

  • Beta cells cannot produce enough insulin or
  • The cells are highly loaded with fat that the insulin receptors curl in and there is insulin resistance or what we call is Metabolic syndrome.

 

  • Because your body either does not produce or does not respond to insulin, your cells do not absorb glucose from your bloodstream, which causes you to have high blood-glucose levels.
  • Because your cells have no glucose coming into them from your blood, your body "thinks" that it is starving.High blood-glucose levels increase the osmotic pressure of your blood and directly stimulate the thirst receptors in your brain.
    • Your pancreatic alpha cells secrete glucagon, and glucagon levels in your blood rise.
    • Glucagon acts on your liver and muscles to breakdown stored glycogen and release glucose into the blood.
  • Your increased urine flow causes you to lose body sodium, which also stimulates your thirst receptors.
  • You are constantly hungry. It's not clear exactly what stimulates your brain's hunger centers, possibly the lack of insulin or high glucagon levels.
  • You lose weight despite the fact that you are eating more frequently. The lack of insulin or insulin-resistance directly stimulates the breakdown of fats in fat cells and proteins in muscle, leading to weight loss.
    • Metabolism of fatty acids leads to the production of acidic ketones in the blood (ketoacidosis), which can lead to breathing problems the smell of acetone on your breath, irregularities in your heart and central-nervous-system depression, which leads to coma.
    • You feel tired because your cells cannot absorb glucose, leaving them with nothing to burn for energy.
    • Your hands and feet may feel cold because your high blood-glucose levels cause poor blood circulation.
      • High blood glucose increases the osmotic pressure of your blood.
      • The increased osmotic pressure draws water from your tissues, causing them to become dehydrated.
      • The water in your blood gets lost by the kidneys as urine, which decreases your blood volume.
      • The decreased blood volume makes your blood thicker (higher concentration of red blood cells), with a consistency like molasses, and more resistant to flow (poor circulation).
      • Your poor blood circulation causes numbness in your hands and feet, changes in vision, slow-healing wounds and frequent infections. High blood glucose or lack of insulin may also depress the immune system. Ultimately, these can lead to gangrene in the limbs and blindness.

 

Fortunately, these consequences can be managed by correcting your high blood glucose through diet, exercise and medications, as we'll discuss next.

New research suggests that :

  • a hormone from the skeleton, of all places, may influence how the body handles sugar.
  • signals from the immune system,
  • the brain and
  • the gut play critical roles in controlling glucose and lipid metabolism.

(Keep reading, it is very interesting, more on the above four in some time)

The Hormone from the skeleton : Researchers at Columbia University  published startling results showing that a hormone released from bone may help regulate blood glucose . In previous work, Dr. Karsenty had shown that leptin, a hormone produced by fat, is an important regulator of bone metabolism. In this work, he tested the idea that the conversation was a two-way street. “We hypothesized that if fat regulates bone, bone in essence must regulate fat,” he said.

Working with mice, he found that a previously known substance called osteocalcin, which is produced by bone, acted by signaling fat cells as well as the pancreas. The net effect is to improve how mice secrete and handle insulin, the hormone that helps the body move glucose from the bloodstream into cells of the muscle and liver, where it can be used for energy or stored for future use. Insulin is also important in regulating lipids.

In Type 2 diabetes, patients’ bodies no longer heed the hormone’s directives. Their cells are insulin-resistant, and blood glucose levels surge. Eventually, production of insulin in the pancreas declines as well.

Dr. Karsenty found that in mice prone to Type 2 diabetes, an increase in osteocalcin addressed the twin problems of insulin resistance and low insulin production. That is, it made the mice more sensitive to insulin and it increased their insulin production, thus bringing their blood sugar down. As a bonus, it also made obese mice less fat.

If osteocalcin works similarly in humans, it could turn out to be a “unique new treatment” for Type 2 diabetes. A deficiency in osteocalcin could also turn out to be a cause of Type 2 diabetes, Dr. Karsenty said.

 

Inflammation : Scientists have long suspected that inflammation was somehow related to insulin resistance, which precedes nearly all cases of Type 2 diabetes. In the early 1900s, diabetics were sometimes given high doses of aspirin, which is an anti-inflammatory. Many researchers agree that obesity is accompanied by a state of chronic, low-grade inflammation in which some immune cells are activated, and that that may be a primary cause of insulin resistance. They also agree that the main type of cell responsible for the inflammation is the macrophage.

 

Brain ; Another participant in the glucose conversation is the brain. Its role has long been suspected. More than a century ago, the French physiologist Claude Bernard suggested that the brain was important in blood sugar regulation. He punctured the brains of experimental animals in specific areas and managed to derange their blood sugar metabolism, making them diabetic.

But for years, virtually no one followed up on this finding. However recently, with more advanced laboratory techniques, has this role been definitively established and expanded upon.

For instance, once scientists developed the ability to manipulate mice so that they lacked particular receptors in specific tissues, they could show that mice without insulin receptors in the brain could not regulate glucose properly and went on to develop diabetes.

And several recent papers suggest that direct signaling by glucose itself to neurons in the hypothalamus is also crucial to normal blood sugar regulation in mice.

“If the brain is getting the message that you have adequate amounts of these hormones and nutrients, it will constrain glucose production by the liver and keep blood glucose relatively low”.  But if the brain senses inadequate amounts, he continued, it will “activate responses that cause the liver to make more glucose, and new evidence suggests that this contributes to diabetes and impaired glucose metabolism.”

 

The Gut : Hormones from the small intestine called incretins turn out to talk directly with the brain and pancreas in ways that help reduce blood sugar and cause animals and people to eat less and lose weight.

Agree with Dr.Udeshi.

Diet to diabetics should be tailored to each patient. Best is to tell the patient or the attendant to make a note of the stuff they commonly eat in a week or record it in the ensuing week plus the daily activities. This will give the rough estimate for the daily calories required and the diet record will direct you as to how to alter their diet within their means to suit their metabolism.

FOOD MANTRA FOR DIABETES

 

Research and my own practical experience with a number of diabetic patients has quite clearly showcased that following a proper diet regime is one of the most important tool for its management. Further it also minimizes complications of blood pressure, high cholesterol, high triglycerides, kidney diseases etc. which usually accompanies diabetes. 

 

Does diet do “miracles”’ or is there a “secret”? Frankly speaking, “No”. It is simply understanding the diet principles and applying them to manage diabetes as per our lifestyle. Charles Weller M.D. in his book "The new way to live with diabetes" (Double Day, New York, 1966 ) says that "Weight reduction and control can bring this incurable disease closer to complete remission than any medication." Total caloric intake must be controlled. Those who are overweight must reduce their caloric intake and those who are underweight must have an adequate intake. The American Diabetes Association in its tips for diabetes  strongly recommends weight management as "the most effective way to treat diabetes." It is believed that obesity hinders insulin from performing. “How much to eat?” We cannot answer this in a general term. For that you would need the help of a qualified dietician.  But “What to eat and What to avoid?” can be explained on scientific manner. In this particular article we will focus on the guiding principles and its practical applications for a days meal of a diabetic – from morning tea to night meal.

 

Morning Tea : Start the day with a cup of tea / coffee with out sugar . Do not go for a walk on empty stomach. Have khakra, roti or bran biscuits. 2 to 4 almonds will be okay. If you are having kidney problem do not drink coffee and let the tea be light.

 

Breakfast: First thing to remember is that the carbohydrate should be complex carbohydrate and amount will depend on calorie allowance for the day and physical activity and disease complication. Never let the breakfast be just of bread / jam or sabudana khichadi or alu parathas. Instead opt out for a combination of breakfast items like poha /upma with sprouts of mung and methi seeds and pomegranates  + non fat milk (without sugar ) + papaya. South Indian may enjoy idli + chutney + sambar instead of poha upma and North Indians may like mixed veg parathas (without oil / ghee /butter) with mint / coriander chutney.  The amount of oil, salt is individualized based on weight, blood pressure etc. Sprouts and some fruits may not be a part of a kidney diet.

 

Mid – Morning :  Many diabetics would prefer the fruit at mid – morning while others would like a cup of hot milk or cold butter milk. Fruits like banana, chiku, grapes, mangoes and custard apple should be avoided or eaten in the right amount after consulting with a dietitian.  Office goers would like to munch on a fistful of roasted chana or sprouts at mid morning.

 

Lunch: The basic lunch can comprise of

 

  • Chappatis or Chappatis + Rice or Bhakris or Rice
  • Pulse or Dal or Fish or Chicken or Egg
  • Vegetable
  • Salad
  • Curds
  • Green Chutney
    1. The Chappati flour should have brown chana and soyabean added to the wheat before the flour is made. After sieving remove dirt and add the bran back to the flour. Bhakris of jowar, bajra, nachni or Rajgeera are also a good option.
    2. Try using brown rice instead of polished, white rice.
    3. Try using various types of pulses and dals. Have atleast 4 pulses a week. Do not over cook them and do not add soda. Brown whole chana should be used atleast once a week. Kidney patients please discuss the use of dals and vegetables with your dietitian.
    4. All vegetables should be used. Vegetable only of potatoes or suran or arbi or raw banana may not be advisable due to their high carbohydrate content. Use of Karela, French beans and cluster beans should be more often.
    5. Take a good helping of salad. Let raw salads be an important and big part of a meal. When ever possible eat salads and fruits with their skin Eg. Kakadi, gajar, muli,tomatoes etc.
    6. Curds should not be sweet and should be low fat or of skimmed milk.
    7. A green chutney is a power house of vitamins and minerals. Hence, let it be a part of every meal.

 

Evening Tea / Snacks : The evening snacks should be light  made up of sprouted veg. bhel or khakra or steamed snacks like idli or muthiya.

 

Dinner: Ideally an early supper is best. Atleast try to have two hours gap between dinner and bed time. As activity is minimum after dinner it is best to keep it light. Increase the volume of the meal by soups, salads. Try vegetable khichadi with kadi or plain veg pulao with soup instead of rice and dal. Incorporate leafy vegetable atleast 4 to 5 time a week. Rest of the diet principles are same as lunch.

 

Night: A cup of low fat milk without sugar is advisable.

 

 

 

 

The second part of the article deals with some specific foods that are scientifically proved to have beneficially effect on sugar control.

 

Karela  or Bitter Gourd:  At least three different groups of constituents in bitter gourd have been reported to have blood-sugar lowering actions of potential benefit in diabetes mellitus. These include a mixture of saponins, insulin-like peptides, and alkaloids. It is still unclear which of these is most effective, or if all three work together. Many research studies have confirmed the benefit of bitter gourd for people with diabetes.

 

Cinnamon: Just half a teaspoon of cinnamon a day significantly reduces blood sugar levels in diabetics, a new study has found. The effect, which can be produced even by soaking a cinnamon stick your tea, could also benefit millions of non-diabetics who have blood sugar problem but are unaware of it.
The discovery was initially made by accident, by Richard Anderson at the US Department of Agriculture's Human Nutrition Research Center in Beltsville, Maryland. They were looking at the effects of common foods on blood sugar. To their surprise apple pie spiced with cinnamon powder did not increase the blood sugar the way other sweets did.   They found out that the active ingredient in cinnamon turned out to be a water-soluble polyphenol compound which mimics insulin, activates its receptor, and help sugars to be taken up by the cells. Alam Khan did a another  postdoctoral   study in Pakistan. Volunteers with Type 2 diabetes were given one, three or six grams of cinnamon powder a day, in capsules after meals. In few  weeks the blood sugar levels  were on average 20 per cent lower than the control group. Some even achieved normal blood sugar levels. However, blood sugar started creeping up again after the diabetics stopped taking cinnamon. The study also showed that cinnamon has additional benefits. In the volunteers, it lowered blood levels of fats and "bad" cholesterol, which are also partly controlled by insulin. And in test tube experiments it neutralised free radicals, damaging chemicals which are elevated in diabetics probably indicating its role as an antioxidant..

 

Raw Vegetables and Fruits: Apart from fiber raw fruits and vegetables have inulin  a precursor of insulin.

 

Chromium: Chromium is needed to activate insulin. Without it, insulin won't work. Chromium is generally found in foods that contain carbohydrate. So the mineral you need to metabolize the sugar is right there at the same time. However, when we refine things to make white foods like white sugar, white flour, and white rice, we remove all the chromium (and any other minerals). We leave behind the sugar and starch that makes the food products taste great, but we no longer include the chromium needed to metabolize it.

Fenugreek (Methi): Scientists at the Pune-based National Centre for Cell Science (NCCS) have prepared a novel formulation from extracts of fenugreek seeds that helps bring down the blood glucose level in the body and hence proves to be a boon for diabetic patients.  In their study on mice, Bhat  found that the formulation helped decreased blood glucose levels by 50-60 per cent and the effect was comparable to that of insulin. The administration of the formulation was done for five consecutive days and it reduced hyperglycemia on day five. What is interesting to know that the anti-diabetic potential of the formulation remained effective for a further 10 days even when methi seed extract was not consumed.

Jamun Fruit :  The berry which usually leaves a grainy feel on the tongue, is a powerhouse of health. It has been officially named as a diabetes-fighter by the studies conducted by Indian Journal of Pharmacology, and Bhabha Atomic Research Center and Central Drug Research Institute for its hypoglycemic (lowering blood sugar) properties. It was found that oral administration of Jamun extracts, from the bark and seeds, boosts insulin levels in diabetics. Studies carried out at the Central Drug Research Institute, Lucknow, show that extracts of seeds of the plant, reduce blood sugar levels and glucosuria in diabetic patients. Fresh seeds are better than the dried ones to serve this purpose.

wow, Dr. Sujata Udeshi, you are awesome!

Thank you for such detailed work , mind if I share it with my colleagues !

You are most welcomed to share. My intension is to educate the common man in a simple realistic and practical way. I will keep adding.

thank u mam for ur detailed description and time

My pleasure

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