DIET should be the mainstay of all diabetic management!

In order to ensure compliance, the prescribed diet should be individualised. It must be realistic, flexible, and take into consideration the patient's likes and dislikes, to as large an extent as possible, and must suit the patient's life style. It is important to educate the patient about the basic requirements of the diet and judge compliance at regular intervals.

"Acceptable" Body Weight

The aim is to attain acceptable body weight with a special emphasis on attaining the desired waist measurement. Other specific changes would be necessary depending on the presence of associated risk factors such as impaired glycemia or diabetes, hypertension, dyslipidemias etc.

Aim initially at slow reduction of 7% to 10% from baseline weight over one year of management. Even small amounts of weight loss are associated with significant health benefits. Continue weight loss thereafter to extent possible with goal to ultimately achieve desirable weight.

Effective weight loss requires a combination of caloric restriction, physical activity, and motivation; effective lifelong maintenance of weight loss essentially requires a balance between caloric intake and physical activity and the maintenance of sufficient skeletal muscle mass/quality.

After 6 months, the rate of weight loss usually declines and weight plateaus because of a lesser energy expenditure at the lower weight and the lifestyle prescription may need to be revised.

Experience reveals that lost weight usually will be regained unless a weight maintenance program consisting of dietary therapy, physical activity, and behavior therapy is continued indefinitely.

The widespread misconception that carbohydrates (in any form) should not be eaten by people with diabetes should be removed. Carbohydrates in the form of simple sugars need restriction. The carbohydrates should be in the form of complex polysaccharides (starch) and contain adequate amount of digestible fibers.

Carbohydrates should constitute around 60-70% of the total calories which is usually found in traditional diets eaten in various parts of India. Very high carbohydrate intakes and/or high glycaemic index foods can exacerbate the dyslipidemia, including hypertriglyceridemia, of the metabolic syndrome, especially if the overall calory intake is very high.

In addition, there should be ample intakes of fresh fruits and vegetables, and whole grains; fruits and vegetables are recommended to provide fiber, vitamins, minerals and hydration, and to increase satiety through the volume of food ingested, in order to avoid feelings of deprivation and restriction.

Protein intake should be approx. 0.8 gms/kg ideal body weight; this usually comprises around 12-18% of the calorie intake.

The requirements for proteins may be increased in catabolic states, pregnancy, lactation and in some elderly patients.

Protein intake may need to be restricted in patients with nephropathy.

Fats should be restricted to around 20-25% of the total calories. If the fat content exceeds 35%, it is difficult to sustain the low intakes of saturated fat required to maintain a low LDL-C. On the other hand, if the total fat content falls below 25%, triglycerides can rise and HDL-C levels can decline; thus, very-low-fat diets may exacerbate atherogenic dyslipidemia.

It is recommended that the saturated fat be <7% of total calories; reduce trans fat; dietary cholesterol <200 mg/dL; total fat 25% to 35% of total calories. Most dietary fat should be unsaturated; simple sugars should be avoided. These goals can be achieved by (1) choosing lean meats and vegetable alternatives; (2) selecting fat-free (skim), 1%-fat, and low-fat dairy products; and (3) minimizing intake of partially hydrogenated fats.

Many foods contains fats; this "invisible fat" should be taken into account when estimating the total fat intake.

Efforts must be made to prescribe adequate amounts of omega-3 fatty acids with the omega 6 (w6) to omega 3 (w3) ratio being as close to the optimal as possible.

The fat intake may need to be further modified if associated dyslipidemia is present.

For a Table of the w3 and w6 content of commonly used cooking media, see Appendix 3a

Salt restriction is necessary in patients with associated hypertension, cardiac failure and fluid overload. Reduce sodium intake to no more than 100 meq/day (2.4 g of sodium or 6 g of sodium chloride / one teaspoon a day). Avoid use of a salt shaker on the dining table.

These can be eaten by diabetics in moderate amounts. Ripe and very sweet fruits are better avoided. Raw and partially ripe fruits are preferable.

If consumed, alcohol should be used in moderation.

Limit alcohol intake to no more than 1 oz (30 ml) of ethanol (eg, 24 oz [720 ml] of beer, 10 oz [300 ml] of wine, or 2 oz [60 ml] of 100-proof whiskey) per day or 0.5 oz (15 ml) of ethanol per day for women and lighter-weight people.

It should be avoided in all diabetics who are severely obese and on a significantly hypocaloric diet, in those who have high triglyceride levels. All other contraindications to alcohol intake also apply to diabetics.

The types of alternative sweeteners that are available are:

• Non-caloric sweeteners like saccharin, cyclamates, sucralose, acesulfame K.
• Aspartame; although this is usually classified as a noncaloric sweetener, it does have a caloric value of 4 calories per gm.
• Non-glucose carbohydrates like fructose, sorbitol, xylitol, lactose, xylitol, isomalt, polydextrose, and maltodextrose. These contain calories and have varying effect on the blood glucose levels.

Most of the non-caloric sweeteners and aspartame are safe if taken in small amounts.