In my last blog I mentioned that carb intake should be 2 exchanges in every major meal a day. The most common answer to this recommendation is “this is too less...I am going to starve” or “I will feel hungry again within an hour”. That’s where proteins come to the rescue...
The right amount of protein intake in every meal reduces hunger and improves satiety but limits muscle mass loss. Patients with diabetes lose around 1 pound of their muscle mass every year as they age, and eating a diet lower in protein is one of the biggest contributing factors. The body uses more energy to digest protein than it does to digest fat or carbs thus preventing a steady and fast rise in blood glucose level and helps achieve weight loss long-term.
Proteins to the rescue …… again Rice based meals in moderate proportions is fine if accompanied by a healthy proportion of legumes or lean cuts (without skin) of chicken or fish, if such a meal is planned with other fibre rich nutrients like green leafy and non-starchy vegetables.
Proteins are made of different amino acids. Some of these are called "essential" because they are necessary and cannot be made by the body. We need to obtain them from our diet. Complete proteins contain ample amounts of all the essential amino acids and are found in fish, poultry, cheese, eggs, and milk. Incomplete proteins do not contain all of the essential amino acid like protein in grains, legumes, and vegetables.
Although, it might seem like meat eaters are better off than vegetarians, it’s not necessarily true. Even though it is important to consume the essential amino acids, it is not necessary to get them only from animal sources.
Good news for vegetarians...There is a dietary strategy called mutual supplementation in which you combine complementary partially complete protein food to supply adequate amounts of all the essential amino acids. For example - beans and brown rice are both quite rich in protein, each lacks one or more of the essential amino acids. However, when beans are combined with brown rice the result is equivalent to a complete protein that can substitute chicken or meat.
Unlike most beans, soybean products (such as tofu and soymilk) are complete proteins. They contain the essential amino acids. Tofu, soy flour, soy-based meat substitutes, soy cheese, and many other soy products are healthy ways to make a meatless diet ‘nutrient complete’.
Some more combinations that can be tried are: Thick lentil soup with a serving of almonds on the side; kidney beans/pinto beans in a corn tortilla; whole-grain pasta tossed with peas; bean soup with whole grain crackers; corn tortillas with beans and rice, soy curry and rice; milk and oats.
How much protein do I need in a day? It is preferable to calculate daily protein intake for people with diabetes as grams per kilogram of body weight and not as a fixed percentage of total energy intake. People with diabetes should not reduce protein intake to less than 1 g/kg of body weight, while protein intake of 0.8–1 g/kg (of body weight) should be recommended for people with diabetes and chronic kidney disease.
Try the following options to meet your recommended protein intake:
What was your protein intake yesterday?
As I mentioned, you need 1 gram/ kg body weight of protein (if you weigh 65 kilograms you need 65 grams of protein / day).
If 1 cup milk/ 2 egg whites/ 1 fist size piece of lean chicken or fish/ 1 med bowl of legumes and pulses/ 1 med bowl of thick yoghurt each will give us approximately 7 grams of protein, can you calculate the amount of protein that you consumed yesterday?
Leave the amount of your yesterdays’ protein intake as a comment for me...
Upcoming Blog - “Fats: The good, the bad and the ugly”
Pariksha Rao is based in Bengaluru, India. She is a clinical nutritionist, IDF certified diabetes educator, sports nutritionist and a lactation expert, with more than a decade of experience across pharmaceuticals, hospitals and research sectors. Having trained over a 1000 paramedics on personalised patient/ consumer care and counselling, Pariksha believes counselling is a holistic approach to achieve long term behaviour modification by setting mutual, achievable, measurable and realistic short term goals.
According to recent WHO report, the prevalence of diabetes in adults worldwide will rise to 380 million in the year 2025. With an all time high obesity and diabetes, the need of the hour is to address the core issues and enable patients to take charge of their own lives.
In this series of blogs I shall be talking about the four main pillars of diabetes management – Diet, Exercise, Medication and Monitoring. Beginning with diet, I shall cover Carbohydrates, Proteins, Fats, eating out options and reading food labels.
In my practice one of the most common reactions to a diagnosis of diabetes is ‘Oh! I’ve never eaten much of sugar, rice, sweets or potatoes etc; and yet I have this disease. Now I can’t eat any of the food that I love.’ This feeling of deprivation is further compounded by societal interference leading to dejection and confusion. Unscientific remedies are tried, which offset any attempts at blood sugar control.
People with diabetes often make wrong assumptions about the reasons for diabetes occurrence and its management. This stems from denial, having to make changes to control it and needing the support of family and friends to combat this life altering and potentially life threatening disease. It is important that patients understand how to control their diabetes through simple and small lifestyle modifications on a daily basis. Diabetes education regarding diet, exercise, medication and monitoring is imperative.
The most important dietary rule of Diabetes: There is NO “Diabetic Diet”.
It is vital to understand that healthy eating isn't about deprivation or denial. Having diabetes need simply translate into eating a variety of foods in moderate amounts and sticking to regular mealtimes. This means choosing a diet that is balanced in all macro-nutrients like carbohydrate, protein, healthy fats and all essential vitamins and minerals. There is no “diabetic diet” as such. It’s a diet that is nutritionally adequate, tasty and individualised, that even people without diabetes may follow to stay healthy.
It is important for a person with diabetes to know which foods will raise their blood sugar to what extent. Carbohydrates contribute the most to blood sugar levels.
Carbohydrates (‘carbs’) are the sugars, starches and fibres found in fruits, grains, vegetables and milk products. There are two types: simple and complex. Whole grains like wheat, oats, barley, pearl millet, whole fruits and vegetables, brown and red rice are all good sources of complex carbs. All these food items when processed into finer grain size and products become simple to digest and increase blood sugar quickly.Bread, cookies, candy, juices, cola, sugar, honey, jaggery are some sources of simple carbs.
Monitoring carbs is the key in achieving glycemic control. Both the amount and type in food influence blood glucose levels. While emphasis should be on increased complex (high fiber) carbs, excess amount of even complex carbs in a meal could lead to high blood sugar.The amount of carbs that maybe consumed is based on multiple factors including activity and medication. This should be constant and ‘binge’ eating is to be avoided.
Eating very low carb diet is detrimental and the recommended range is 45–65%of total calories. So, restricting total carbs to <130 g/day (approximately 6 cereal exchanges/ day) could impair the functioning of brain and heart and lead to hypoglycemia (low blood sugar). Despite the person`s wishes, families find it difficult to follow a restrictive carb plan and I have often seen such rigid approaches contributing to disordered eating behaviour.
(Cereal Exchange: an exchange can be understood as 1 palm sized tortilla, 1 medium sized bowl of brown rice, 1 fistful of pasta, 1 palm sized chapatti, 1 medium bowl of broken wheat or oats porridge, 1 slice (3 X 3 inch) of whole wheat bread.)
Carbs are a must in every major meal especially after alcohol consumption to regulate sugar levels and avoid hypoglycemia.
Different methods may be used to estimate the carb content of meals like:
So what is needed is to understand what food item is a source of healthy complex carbs, and have minimum 6 exchanges per day (2 cereal exchanges/ meal) and keep in between snacks protein rich.
Upcoming Blog - “Proteins to the rescue”
Author - Pariksha Rao is based in Bengaluru, Imdia. She is a clinical nutritionist, IDF certified diabetes educator, sports nutritionist and a lactation expert, with more than a decade of experience across pharmaceuticals, hospitals and research sectors. Having trained over a 1000 paramedics on personalised patient/consumer care and counselling, Pariksha believes counselling is a holistic approach to achieve long term behaviour modification by setting mutual, achievable, measurable and realistic short term goals.
“The big talent is persistence”. Octavia E. Butler
It is always extremely difficult to ascertain why human behaviour does not correspond with agreed recommendations from a healthcare provider, whether it is in following diet, exercise, lifestyle changes or taking medications. In diabetes, approximately half are not able to do so, resulting in poor control of diabetes. This has far reaching consequences - increased heart attacks, stroke, amputations, kidney and eye problems, along with economic implications. The ability of physicians to recognize non adherence is poor, and interventions to improve adherence have had mixed results.
A number of reasons have been suggested and it is probably combinations of these factors that are responsible. Majority of diabetics are on multiple medications and complex regimes due to many coexisting conditions. Some are forgetful, or miss doses due to being preoccupied with other more pressing activities. Some are unable to tolerate or have side effects like hypoglycemia and weight gain. Sometimes people with high blood glucose levels have difficulty in reading labels and this should be kept in mind.
The perception of benefits of treatment can also have a significant effect on adherence. People have their own assumptions about their risks of complications and side effects, which leads to reduced adherence to treatment. There is also a considerable resistance to injectable medications. Some of the reasons are injection phobia, negative impact on work, permanent need for insulin, inconvenience, not believing insulin was necessary, hypoglycemia, less flexibility and feeling of failure. People adhere well when the treatment regimen makes sense to them, when it seems effective, when they believe the benefits exceed the inconvenience, when they feel they have the ability to succeed at the regimen, and when their environment supports regimen-related behaviours.
A very oft reported problem is that communication between the patient and the provider is not adequate and this barrier leads to misunderstandings. As diabetes is a long journey, adherence is influenced by the changing situations in a person`s life. Various life`s events influence human behaviour, either good or bad, may result is deviation from set practices and result in poor adherence.
Though numerous methods have been tried, there is not one simple solution. The first and foremost is to win the confidence of patients by improved two way communication with a non-judgemental approach. Reduced treatment complexity, regimen coordination with daily life (eg, meals, waking, bedtime, brushing teeth, etc), fixed-dose combinations and decreased frequency of administration of medications are important. Weight gain and hypoglycaemia are important issues, which must be discussed in details and pre-emptive advice must be given.
Diabetes is associated with multiple psychological problems, some of which may not be clinically apparent. This has a bearing on adherence. Social support influences the ability to adjust to and live with illness and patient adherence. Assistance and support from friends and family have been implicated in promoting patient adherence by encouraging optimism and self-esteem, buffering the stresses of being ill, reducing patient depression, improving sick role behaviour and giving practical assistance. The presence of close others may result in the direct or indirect control of behaviour and facilitating adherence. However, a non-supportive relationship maybe toxic and have an opposite effect.
A collaborative approach to care augments adherence. People who have difficulty maintaining adequate adherence need more intensive strategies than do patients who have less difficulty with adherence, a more forgiving medication regimen, or both. A useful approach could be to create a social strategy with involvement of medical, lifestyle and mental health experts to empathise, motivate and provide continuous guidance. Regular monitoring of blood sugar levels using cloud services and forthwith action which is pragmatic and with person involvement bolsters confidence. Importantly, people should have help and guidance at hand and should have people to speak to. This can be done remotely using video link, text messaging and chat using mobile health. As travel takes up a lot of time and is inconvenient, this can be done from a place of choice of both the provider and the patient.
Other new technologies such as reminders through mobiles and pillboxes may be needed to help patients who have the most difficulty meeting the goals of a regimen. Medication apps represent a possible strategy that can be recommended to non-adherent patients and incorporate into their practice. It is important to make the person believe that whatever strategy is used, people with good diabetes self-care behaviours can attain excellent control.
“Problems are not stop signs, they are guidelines. Robert H. Schuller”
The maintenance of strict glucose control is unassailable in diabetes, but hypoglycaemia (low blood sugar) is one of the major limiting factors on account of its morbidity and mortality. Though it is regarded as more common in Type I Diabetes, its occurrence in Type II Diabetes is often underestimated for a number of reasons, predominant of which is underreporting? Contemporary research, clinical experience and speaking to people with diabetes in non-clinical settings show that it occurs with much higher frequency than previously thought or reported. This has far reaching implications for safe management in the community and healthcare professionals and people alike sometime chose a guarded option and higher blood glucose levels are maintained which predispose people to more vascular complications.
In the UK hypoglycaemia means blood sugar levels less than 4 mmol/l. When this can be managed by the person themselves, it is regarded as mild and when third party intervention is needed it is regarded as serious. Though more common in people on insulin, it is also frequently associated with intake of sulphopnylureas (such as glibenclamide, gliclazide, glipizide, glimepiride, tolbutamide.With increasing use of insulin for Type II diabetes, the problem is likely to escalate. Though analog insulins do offer better protection, it is by no means absolute.
The brain is extremely vulnerable to falling blood sugar levels as it neither has the ability to synthesise nor store glucose. When blood sugar falls, counterregulatory hormones of which glucagon and epinephrine (adrenaline) are the most potent are secreted and cognitive, physiological, and symptomatic changes occur. The recognition of symptoms is fundamental to self-management of hypoglycaemia. If (even mild) hypoglycaemia episodes recur often over time (e.g., once a day), symptoms are produced at a much lower blood sugar level. This is dangerous because symptoms are produced when the blood sugar level is precipitously low. In turn, failure to sense symptoms of hypoglycaemia (hypoglycaemia unawareness) increases the risk of prolonging duration and increasing frequency of hypoglycaemia. These events lead to a vicious circle leading to an increase in severe hypoglycaemia with brain dysfunction. Well-known risk factors for the development of hypoglycaemia include exercise, alcohol, older age, renal dysfunction, infection, decreased intake of energy, and mental health issues, including dementia, depression, and psychiatric illnesses. Though there is no conclusive evidence for long term deleterious impact of recurrent moderate hypoglycaemia on brain function, this is probably relevant for simple tasks, but may perhaps lead to impairment at times of performing complex tasks like driving.
The challenge is to lower blood glucose to near normal values in order to lower the risk for long-term complications, but at the same time minimize hypoglycemia- and hypoglycemia- associated morbidity and mortality. The goal is also to manage most people with diabetes in the community. Continuous glucose monitoring is one of the methods used, which is constantly being evolved to be more accurate. In addition to this is the ability to transmit blood sugar readings from glucometers to the healthcare providers by using the internet (cloud services) via mobile devices in real time. This also has the ability to analyse and prepare trends which are useful for decision making. In addition to this, digital health has the ability to establish a two way communication between healthcare providers and people for providing advice by using multiple platforms like video link, text chat and messaging.
An episode of hypoglycemia maybe quite miserable and have far reaching consequences. Often these people try to conceal these symptoms as these have social and economic implications. Thus they need both support regarding their lifestyles and emotional support. It is vital that they have lifestyle and mental health trained professionals to speak to and interact with for them to be further educated to make the necessary adjustments that are needed. Most importantly, it is important to win the confidence of these people that they live in a supportive community and there is help and correct guidance at hand. This can also be done remotely by using mobile health services and in the comfort of the person`s choice of place.