At the end of the session, participants must be able to,

1. Describe diabetes as a disease,

2. List the components of medical nutrition therapy and lifestyle modification in diabetes management,
3. Identify the role of meal supplements in diabetes
4. Enumerate the key features of Glucosure

I. Diabetes as a disease

Diabetes is a condition in which the body does not properly process food for use as energy.
-Center for Disease Control
It is a chronic disease, which occurs when the pancreas does not produce enough insulin, or when the body cannot
effectively use the insulin it produces. This leads to increased amounts of glucose in the blood.
-World Health Organization

Diabetes is now classified into 4 general categories.

1. Type 1 diabetes due to β-cell destruction usually leading to absolute insulin deficiency.
2. Type 2 diabetes due to progressive loss of insulin secretion on the background of insulin resistance
3. Gestational diabetes mellitus which is diagnosed on the second or third trimester of pregnancy (not
clearly overt diabetes)
4. Specific types of diabetes due to other causes, e.g. drug or chemical-induced diabetes, other diseases
of the pancreas
- Diabetes Care 2016;39 (S1):S13-S22. American Diabetes
Association

Among these types, it is type 2 diabetes that accounts for about 90-95% of all diagnosed cases.

Risk factors include:

Age – type 2 DM increases with age: ADA recommends tests for type 2 DM starting at age 45 especially if
overweight or obese
Belonging to these race/ethnic groups- African-American, Latino, Native American, Asian
Cardiovascular Factors: smoking, dyslipidemia, abdominal obesity, Family history, established CV or renal
disease: stroke, myocardial infarct, coronary artery disease, elevated creatinine, macroalbuminuria, low
GFR, advanced retinopathy

Burden of Disease

Data shows that there is an Asian form of type 2 DM that is different from Caucasians. Asians have different
demographic and socio-cultural characteristics. T2DM is seen to develop at a younger age, usually a decade earlier
than Caucasians.
Diabetes among Filipinos is said to be not exclusively mediated by obesity per se, as increased rates are seen in
relatively lower BMIs versus Caucasians. Data would show that more than obesity, it is the excess visceral adipose
tissue accumulation (waist-to-hip ratio) that drives the risk. This excess visceral adiposity is associated with low
adiponectin , which in turn, is strongly implicated in the development of type 2 DM. Adiponectin is a hormone of fat
cell origin that is involved in the control of circulating glucose and lipid levels.
As diabetes starts early in life among Asians including Filipinos, this brings with it associated increase in morbidity
and mortality and a lifetime risk of cardiovascular disease. Newly diagnosed adult T2DM patients (mean age of 50
years) showed high prevalence of diabetic complications at the onset of their DM diagnosis.

2. Medical Nutrition Therapy

For many diabetics , the most challenging part is determining what to eat. The position of the ADA is that there is no
one-size-fits-all eating pattern and therefore recommends that in overall DM management, each patient must be
actively engaged in self management, and treatment. The goals of MNT are:
A healthful eating pattern to improve health, specifically:
Achieve and maintain weight goals
Attainment of individualized glucose levels, blood pressure and lipid goals
Type 2 diabetes prevention or delay

Appropriate diet for Patients with DM

There is no single ideal dietary distribution of calories among carbohydrates, fats and proteins for people with
diabetes. Macronutrient distribution should be individualized (ADA, 2016) and the emphasis is in appropriate portion
sizes (plate). For the macronutrients below, it is important to remember that the recommendations hold even for
prediabetics.
Carbohydrate intake from whole grains, vegetables, fruits, legumes and dairy products, with emphasis on
fiber and lower in glycemic load/glycemic index
Avoidance of sugar-sweetened beverages.

In individuals with Type 2 DM, ingested protein appears to increase insulin response without increasing
plasma glucose.

An eating plan emphasizing elements of a Mediterranean-style diet rich in MUFA may improve glucose
metabolism and lower CVD risk. Foods rich in omega-3 FA and nuts and seeds (ALA) is recommended to
prevent or treat CVD but there is no evidence to support use of omega-3 supplements.

People with DM should limit sodium consumption to <2,300 mg/day, although further restriction may be
indicated for those with both DM and hypertension.

The Philippine DNA has specific nutrition recommendations for Diabetes in the Philippines because it was
agreed upon that food composition influence the development, progression and control of diabetes.

Macronutrient Specific Recommendations

Carbohydrates Mostly complex or high fiber (total of 25-50 g /day)
45-65% of daily energy intake
NOT <130gm/day in patients on low calorie diets
Proteins 15-20% of total energy intake
NOT < 1gm/kg in patients with normal kidney function
Fats < 30% of total energy intake
<7% of saturated fats
Trans-fats should be eliminated

Lifestyle Modifications
Adults with diabetes should be advised to perform at least 150 min/week of moderate intensity aerobic
physical activity (50-70% of maximum heart rate), spread over at least 3 days a week with no more than 2
consecutive days without exercise.

All individuals should be encouraged to reduce sedentary time or to break up extended amounts of time >90
minutes spent sitting.

Resistance training at least 2x a week is encouraged provided there are no contraindications.

 Both resistance training and endurance exercise appear to have beneficial effects on waist circumference,
insulin sensitivity, and thus diabetes risk . The preventative effects of exercise appear to extend to the
prevention of gestational diabetes mellitus (GDM) as well.

3. Role of Meal Supplements in Diabetes Management

The Philippine Diabetes Nutrition Algorithm recognizes the role of diabetes-specific formulas as part of
MNT. These formulas are designed to help in glycemic control and have been demonstrated to improve glycemmic
profiles and reduce disease complications with proper advice of the MD or a dietician.

For patients with low BMI especially the elderly, caloric supplementation of their regular meals with these
formulas help in upbuilding and in filling nutritional deficiencies.

For patients with normal or elevated BMI, replacement, caloric replacement of a regular meal may be helpful
in achieving weight loss and greater metabolic control.

Meal supplements with low carbohydrate and high MUFA help improve glycemic control versus standard
formulas.(Glycemia Targeted Specific Nutrition)

4. Key Features of Glucosure

Guide Source % Protein % Fat % Carbohydrates

Philippine RDA 2015 10-15 15-30 55-75
CODEX Guide on Nutrition 10-35 20-35 45-65
Labeling 2005
Phil DNA 15-20 <30 45-65
Glucosure 19.1 30 44

Fructose

The human body handles glucose and fructose — the most abundant sugars in our diet — in different ways. Almost
every cell in the body can break down glucose for energy but the only ones that can handle fructose are liver cells.
What the liver does with fructose, especially when there is too much in the diet, has potentially dangerous
consequences for the liver, the arteries, and the heart.

Refined sugar, called sucrose, is half glucose and half fructose. High-fructose corn syrup is about 55% fructose and
45% glucose. We see them today in breakfast cereals, pastries, sodas, fruit drinks, and other sweet foods and
beverages.

The entry of fructose into the liver kicks off a series of complex chemical transformations. One remarkable change is
that the liver uses fructose, a carbohydrate, to create fat. This process is called lipogenesis. Give the liver enough
fructose, and tiny fat droplets begin to accumulate in liver cells . This buildup is called nonalcoholic fatty liver disease,
because it looks just like what happens in the livers of people who drink too much alcohol.

The breakdown of fructose in the liver does more than lead to the buildup of fat. It also:
- elevates triglycerides
- increases harmful LDL (so-called bad cholesterol)
- promotes the buildup of fat around organs (visceral fat)
- increases blood pressure
 - makes tissues insulin-resistant, a precursor to diabetes
- increases the production of free radicals, energetic compounds that can damage DNA and cells.
- None of these changes are good for the arteries and the heart.

- http://www.health.harvard.edu/heart-health

1. Fructose does not stimulate Insulin Release (no GLUT5 in ß cells) ,

so Fructose consumption does not dampen appetite .
2. " Fructose has been implicated as a contributor to nearly all of the classic
manifestations of the Insulin Resistance Syndrome ."
3. Fructose feeds sugar continuously into Fat production .
4. Fructose when eaten just before 2 hours of exercise is oxidized (burned)
less than is Glucose or Resistant Starch (54% vs 70%).

Sugar Alcohols

Sugar alcohols are carbohydrates that chemically have characteristics of both sugars and alcohols

Sugar alcohols are found naturally in small amounts in a variety of fruits and vegetables and are also commercially
produced. Commercially produced sugar alcohols are added to food as reduced calorie sweeteners and are found in
chewing gums, dairy desserts, cakes and cookies, falvored jams and jelly spreads.

Some examples of sugar alcohols are: arabitol, erythritol, glycerol, hydrogenated starch hydrolysates (HSH), isomalt,
lactitol, maltitol, mannitol, sorbitol, and xylitol.

Sugar alcohols can produce abdominal gas, bloating, and diarrhea in some individuals because they are not
completely absorbed by the body and are fermented by bacteria in the large intestine. For this reason, foods that
contain the sugar alcohols sorbitol or mannitol must include a warning on their label that states “excess consumption
may have a laxative effect.

Fiber

Benefit for those with diabetes

Soluble fibre in oat bran, legumes (dried beans of all kinds, peas and lentils), and pectin (from fruit, such as apples)
and forms in root vegetables (such as carrots) is considered especially helpful for people with either form of diabetes.
Soluble fibre may help control blood sugar by delaying gastric (stomach) emptying, retarding the entry of glucose into
the bloodstream and lessening the postprandial (post-meal) rise in blood sugar. It may lessen insulin requirements in
those with type 1 diabetes. Because fibre slows the digestion of foods, it can help blunt the sudden spikes in blood
glucose (sugar) that may occur after a low-fibre meal. Such blood sugar peaks stimulate the pancreas to pump out
more insulin. Some researchers believe that a lifetime of blood glucose (sugar) spikes could contribute to type 2
diabetes, which typically strikes after the age of 40, and more than doubles the risk of stroke and heart disease. The
cholesterol-lowering effect of soluble fibres may also help those with diabetes by reducing heart disease risks.

-http://www.diabetes.ca/diabetes-and-you
Low Glycemic Index

The glycemic index, or GI, measures how a carbohydrate-containing food raises blood glucose. Foods are ranked
based on how they compare to a reference food — either glucose or white bread.

A food with a high GI raises blood glucose more than a food with a medium or low GI.

Meal planning with the GI involves choosing foods that have a low or medium GI. If eating a food with a high GI, you
can combine it with low GI foods to help balance the meal.

Research shows that both the amount and the type of carbohydrate in food affect blood glucose levels. Studies also
show that the total amount of carbohydrate in food, in general, is a stronger predictor of blood glucose response than
the GI.

Based on the research, for most people with diabetes, the first tool for managing blood glucose is some type
of carbohydrate counting. This will be part of the lecture.

Because the type of carbohydrate can affect blood glucose, using the GI may be helpful in "fine-tuning" blood
glucose management. In other words, combined with carbohydrate counting, it may provide an additional benefit for
achieving blood glucose goals for individuals who can and want to put extra effort into monitoring their food choices

- http://www.diabetes.org/food-and-fitness/food/what-can-i-eat/understanding-carbohydrates/glycemic-index-and-
diabetes.html

Summary of features

1. Glucosure has zero fructose.

2. It has the highest amount of fiber among all existing brands in the market (15.1 grams/100 gram powder vs
2.05 gms in Glucerna, 8.7 gms in Nutren DM, 6 gms in Diabetasol and 8 gms in Diabetamil)

3. It has a low glycemic index. Its carbohydrate per serving is equal to ½ cup of rice (23 grams, FNRI) and will
be easy to compute for carbohydrate exchange.

4. It has zero sugar alcohols unlike Glucerna and Nutren DM (sorbitol).