Medical Nutrition Therapy for Type I Diabetes Mellitus

Abstract

Diabetes mellitus is described by high blood glucose level resulting from deficiencies in insulin secretion, insulin action, or both. Type 1 diabetes is a condition in which pancreatic beta-cell get destructed and leads to absolute insulin deficiency. Lack of insulin causes hyperglycemia, polyuria, polydipsia, polyphagia, body mass loss, dehydration, electrolyte disturbance, and ketoacidosis. MNT necessitates an individualized tactic and effective nutrition self-management education, recommendation, and support. A key component of MNT is the provision of adequate calories for normal growth and development for children and adolescents with T1DM. The patient should monitor their saccharide intake either through saccharide counting or meal planning exchange lists for flexibility and variety in meals. Saccharide intake from whole grains, vegetables, fruits, legumes, and dairy products, with an emphasis on foods higher in fiber and lower in glycaemic load, should be advised over other sources, especially those containing sugars. Saccharide counting is helpful for people with diabetes in managing blood glucose level by tracking the grams of saccharide consumed at meals. All persons with T1DM need a substitute of insulin that mimics normal insulin action. An insulin-to-saccharide ratio can be established for an individual that will guide determinations on the amount of mealtime insulin to infuse.

1. Introduction

Diabetes mellitus is described by high blood glucose level resulting from deficiencies in insulin secretion, insulin action, or both. Insulin is a hormone that is essential for the use or storage of body fuels that are Saccharide, protein, and fat. Beta-cells of the pancreas produce insulin. Persons with diabetes do not produce sufficient insulin; hyperglycemia (elevated blood glucose) occurs with insulin shortage [1] This chapter provides nutritional information regarding nutrients requirement, glycemic content of several foods, adjusting food’s saccharide according to the insulin doses, medical nutrition therapy, idea about saccharide count for type 1 diabetic persons, management of blood glucose during exercise, and management of type 1 patient during sick days. This chapter would be helpful for type 1 patients and their caretaker, nutritionist, nurses, and doctors.

1.1 Type 1 diabetes

Type 1 diabetes is a condition in which pancreatic beta-cell get destructed and leads to absolute insulin deficiency. Lack of insulin causes hyperglycemia, polyuria, polydipsia, polyphagia, body mass loss, dehydration, electrolyte disturbance, and ketoacidosis [1].

T1DM has two varieties: immune-mediated and idiopathic.

1. Immune-mediated diabetes mellitus is outcome from an autoimmune devastation of the beta-cells of the pancreas.

2. Idiopathic T1DM states to forms of the disease that have no recognized etiology. Although only a marginal of individuals with T1DM fall into this category. Most of them are of African or Asian origin [2].

At this time there are no known means to thwart T1DM. Persons with T1DM are reliant on exogenous insulin to inhibit ketoacidosis and death. T1DM can develop at any age. Although more cases are diagnosed in people earlier than the age of 30 years, it also occurs in older individuals [1].

Around 17–30% of persons with T1DM have autoimmune thyroid disease., and celiac disease happens in 1–16% of persons contrasted with 0.3–1% in the common population [2]. Children with T1DM should be screened for celiac disease soon after diagnosis. If celiac disease is biopsy-confirmed, children should be placed on a gluten-free diet by a registered dietitian nutritionist (RDN) experienced in managing diabetes and celiac disease [1].

There are two types of normal physiological insulin secretion: continuous basal insulin secretion and incremental prandial insulin secretion, controlling meal-related glucose excursions. Individuals with type 1 and insulin-requiring type 2 diabetes lack both basal and meal-related prandial secretion. Historically, conventional treatment included predetermined or “fixed” insulin doses and following a rigid calorie- and saccharide-controlled meal plan based on the insulin regimen. Some individuals with type 1 and insulin-requiring diabetes still use this method for a variety of reasons, such as age, cost, fewer required injections, lack of access to insulin analogs, personal preference, or prescribing habits of the health care provider [3].

2. Medical nutrition therapy (MNT)

MNT necessitates an individualized tactic and effective nutrition self-management education, recommendation, and support. It is essential for total diabetes care and management. Supervising glucose, HbA1C and lipid level, blood pressure, body mass, and quality-of-life issues is essential in assessing the success of nutrition-related recommendations [1].

The goals of MNT are usually stated as:

• Stabilizing specific dietary suggestions with the limits of insulin therapy

• Minimizing hypoglycemia

• Conforming to ideal growth and development in young people

• Decreasing adverse metabolic and cardiovascular effects of acquired insulin resistance

• Diminish the risks of microvascular problems by maintaining the lowest practicable and safe HbA1C and glucose level.

• Empowering the person having diabetes along with their family members with the right food choices and options to maintain the pleasure of eating.

• Providing practical tools for developing healthy eating patterns rather than focusing on individual macronutrients, micronutrients, or single foods and emphasizing nutrient-dense foods rather than calorie-dense foods.

• Emphasizing the importance of chew count, saccharide count, and portion control to achieve good glycemic control.

• Developing meal planning with patients and sharing plan with the medical team so an insulin regimen could be integrated into the patient’s usual lifestyle.

2.1 Energy requirements for T1DM

A key component of MNT is the provision of adequate energy for normal growth and development for children and adolescents with T1DM. Therefore it is important to screen growth by assessing height and body mass every 3 months and recording it on growth charts. Usual energy intake can be adjusted to accommodate growth or to prevent excessive body mass (Table 1) [4].

Guidelines for daily Energy Requirement in Children
4184 KJ + 418.4KJ/year age (for 0–12 years old)
6276–8368 KJ + 418.4KJ/year age > 12 (for females 12–15)
8368–10,460 KJ + 8368KJ/year age > 12 (for males 12–15)

Table 1.

Calculation of energy requirements in T1DM.

source: [5].

3. Macronutrients distribution and eating patterns

The macronutrients distribution should be based on individualized assessment of current eating patterns and preferences, while keeping total calorie and metabolic goals in mind.

3.1 Saccharide

Evidence is inconclusive for an ideal amount of saccharide intake for an individual with diabetes. The type and amount of saccharide are both important. The patient should monitor their saccharide intake either through saccharide counting or meal planning exchange lists for flexibility and variety in meals.

Saccharide intake from whole grains, vegetables, fruits, legumes, and dairy products, with an emphasis on foods higher in fiber and lower in glycaemic load, should be advised over other sources, especially those containing sugars. Regulated saccharide at each meal and snack should be provided, with set doses of insulin in diabetics receiving insulin. Visible sugar can be restricted to <10% of total energy intake [5].

Evidence exists that the amount and type of saccharide eaten affect blood glucose level; however, the total amount of saccharide eaten is the primary interpreter of glycemic response. Day-to-day steadiness in the number of saccharide eaten at meals is reported to improve glycemic control, especially in persons on fixed insulin regimens. Whereas in persons with T1DM who adjust their mealtime insulin doses or who are on insulin therapy, insulin doses should be regulated to match saccharide intake [3].

Saccharide counting is an eating plan technique based on the theory that all types of saccharide (except fiber) are digested with the majority being absorbed into the bloodstream and that the total amount of saccharide consumed has a greater outcome on blood glucose elevations than the specific type. Saccharide counting is helpful for people with diabetes in managing blood glucose level by tracking the grams of saccharide consumed at meals. Persons are encouraged to keep protein and fat food sources as steady as possible because they do not importantly disturb blood glucose level even though they require insulin for metabolism.

$$\mathrm{\text{One saccharide count/choice or serving}}=\mathrm{\text{Approx. 10}}=–\mathrm{\text{15 grams of saccharide}}$$E1

Counting saccharide servings provides an accurate ‘guess’ of how the blood glucose will rise after a meal or a snack. Monitoring total grams of Saccharide by use of saccharide counting remains the key strategy in achieving glycemic control for people with T1DM.

Choice and quality of saccharide depends on Glycemic index (GI) and Glycemic Load (GL) of the food.

3.1.1 Glycemic index and glycemic load

The glycemic index (GI) of food was developed to compare the physiologic influences of Saccharide on glucose. The GI is a method used to categorize food based on how they impact blood glucose. The GI measures the relative area under the postprandial glucose curve of 50 g of digestible Saccharide compared with 50 g of a reference food, either glucose or white bread. The GI does not measure how rapidly blood g lucose level increase. The peak glucose response for individual foods and meals, either high or low GI, occurs at approximately the same [6]. It is the ranking of foods from 0 to 100 based on their immediate effect on blood glucose level (Table 2).

High	(70 and above)
Medium	(56–69)
Low	(55 and under)

Table 2.

The common classification of GI of foods is as follows:

source: [5].

Glycemic load (GL) is a ranking system that corrects the glycemic index for the number of saccharide in a typical serving size. We cannot deliberate a food’s glycemic index without taking the glycemic load into account. The GL takes the GI one step further and quantifies the rise in blood sugar based on the number of saccharide the food contains in a typical serving. The estimated GL of foods is calculated by multiplying the GI by the amount of digestible saccharide and divided by 100 in each food (digestible saccharide = total saccharide – Dietary Fiber)

$$\mathrm{\text{GL}}=\mathrm{\text{(Digestible saccharide per serving × GI)}}/100$$E2

The study found that watermelon has a high GI that is 76 but it is mostly holding water; a typical 100-gram serving of watermelon has 7-gram digestible saccharide. Now the GL of watermelon is 5.32 (76 × 7/100 = 5.32). This categorizes watermelon as a low GL food. So, a typical serving size will not cause a huge spike in blood glucose. Overall the GL is a better reflection of expected blood glucose responses to foods based on how much we usually eat in a serving makes it more useful than the GI (Table 3 and Figure 1).

High	≥ 20
Medium	11 to 19
Low	≤ 10

Table 3.

Classification of GL.

source: [5].

Figure 1.

Schematic diagram of the influence of GI or GL on blood glucose (left axis) or insulin (right axis). Low vs. medium vs. high GI or GL and their corresponding value range are indicated [7].

3.1.2 Fiber and whole grains

The suggestions for fiber intake for people with diabetes are similar to the suggestions for the common public. Diets containing 44 to 50 g of fiber daily improve glycemia; It is unknown if free-living individuals can daily consume the amount of fiber needed to improve glycemia. However, eating foods containing 25 g fiber per day for adult female and 38 g per day for adult male is expectant. As with the common people, individuals with diabetes should eat at least half of all grains as whole grains [1].

3.1.3 Saccharide distribution across meals

There are two main Eating tactics for using saccharide counting; using insulin-to-saccharide ratios to regulate premeal insulin doses for variable saccharide intake, or following constant saccharide eating plan when using fixed insulin regimens. Testing pre and post-meal blood glucose level is significant for making regulations in either food intake or medication to achieve blood glucose goals.

Depending on the type of insulin prescribed, mid-meal and bedtime snacks may or may not be necessary. For example, if the patient is on a combination of long-acting and rapid-acting analog insulin, a mid-meal, and a bedtime snack are not necessary. However, if a patient is on conventional premix insulin or regular insulin before meals and intermediate-acting insulin pre-dinner, a mid-meal and a bedtime snack are important.

For patients on rapid-acting insulin, low saccharide-containing foods should be prescribed at mid-meals or the patient must take rapid-acting insulin for a saccharide-containing snack based on his insulin to saccharide ratio [5].

3.2 Protein

Protein intake goals should be individualized based on current eating patterns as well as the presence of other comorbidities.

3.2.1 Recommendations for protein intake

The amount of protein usually consumed by persons with diabetes (15–20% of energy intake) has the smallest acute effects on glycemic response, lipids, and hormones, and no long-term effect on insulin supplies. For people with diabetes, evidence is indecisive to recommend an ideal amount of protein intake for enhancing glycemic control or improving CVD risk factors; therefore aims should be individualized [3]. 20–25% of the total calories from protein sources is recommended by the International Society for Pediatric and Adolescents with diabetes [8]. Prefer 50% of protein intake from high biological value protein. Protein intake with every meal is suggested to reduce the glycaemic response. For those with diabetic kidney disease, dietary protein should be kept at 0.8 g/kg body mass/day. Individualization is the key.

Although nonessential amino acids go through gluconeogenesis, in well-controlled diabetes, the glucose generated does not appear in the general circulation; the glucose generated is likely stored in the liver as glycogen. When glycolysis occurs, it is unknown if the primary source of glucose was saccharide or protein. Although protein is just as potent a stimulant of acute insulin proclamation as saccharide, it has no long-term outcome on insulin needs. Totaling protein to the treatment of hypoglycemia does not stop subsequent hypoglycemia and the addition of protein only adds up unnecessary and usually annoying calories. Furthermore, protein does not lengthy the absorption of Saccharide and should not be added to snacks (or meals) to counteract hypoglycemia [1].

3.3 Fats

Fats are an essential part of a healthy diet and they should not be evaded they should be consumed daily. Evidence is uncertain for an ideal amount of total fat intake for people with diabetes. Therefore, goals should be individualized. Fat quality appears to be far more imperative than quantity.

The amount of dietary fat, cholesterol, and trans-fat recommended for people with diabetes is the same as that recommended for the general population, i.e. >10% of Total energy intake (TEI) from monounsaturated fatty acid (MUFA), of TEI from polyunsaturated fatty acid (PUFA), of TEI from saturated fatty acid (SFA) and nil Trans-fats. Besides glycaemic index and glycaemic load, saccharide counting does not take into account protein or fat content but, stimulation of insulin release is multifactorial [5].

Protein and fat, if consumed in large amounts can slow down the breakdown of Saccharide from the meal causing the blood glucose level to rise gradually. Fat delays gastric emptying releasing glucose slowly and hence does not cause an immediate spike in blood glucose level.

3.4 Alcohol

Risks related to alcohol intake include hypoglycemia (particularly for those using insulin or insulin secretagogue therapies), body mass gain, and hyperglycemia (for those consuming excessive amounts). In adults with diabetes, intake should be limited to one drink per day or less for women and two drinks per day or less for men. One standard drink is equal to 12 ounces of regular beer, 5 ounces of wine, and 1.5 ounces of distilled spirits [5].

3.5 Micronutrients

There is no clear evidence of benefit from vitamin or mineral supplementation in people with diabetes who do not have an underlying deficiency. In limited groups such as the elderly, pregnant or lactating women, strict vegetarians, or those on calorie-restricted diets, a multivitamin supplement may be needed. A diet that is low in sodium (less than 2300 mg per day) can help manage blood pressure [5].

4. Insulin

Insulin is a hormone produced in the β-cells of the pancreas, which are part of the Islets of Langerhans. β-cells release insulin, with each meal and help the body use or store the blood glucose. In type 1 diabetes, the pancreas no longer secrets insulin. The β-cells have been destroyed and they need insulin shots to use glucose from meals.

4.1 Types of insulin

4.1.1 Rapid-acting insulin

Insulin lispro (Humalog), insulin aspart (Novolog), and insulin glulisine (Apidra) are rapid-acting insulins. They are used as bolus (premeal or prandial) insulins. They are insulin analogs that contrast with human insulin in amino acid sequence. It binds to insulin receptors and thus functions like human insulin (Table 4).

Rapid-Acting	Onset of Action	Peak Action	Usual Effective Duration
Insulin lispro (Humalog)	<0.25–0.5 hr	0.5–2.5 hr	3–6.5 hr
Insulin aspart (NovoLog)	<0.25 hr	0.5–1.0 hr	3–5 hr
Insulin glulisine (Apidra)	<0.25 hr	1–1.5 hr	3–5 hr

Table 4.

Rapid-acting insulin.

Adapted from Kaufman FR editor: Medical management of type 1 diabetes, ed 6, Alexandria, Va, 2012, American Diabetes Association.

4.1.2 Regular insulin

Short-acting insulin with a gentler onset of action and later activity peak. For the greatest outcomes, the slow onset of regular insulin requires it to be taken 30 to 60 minutes before meals (Table 5).

Short-Acting	Onset of Action	Peak Action	Usual Effective Duration
Regular (Humulin R and Novolin R)	0.5–1 hr	2–3 hr	3–6 hr

Table 5.

Regular insulin.

Adapted from Kaufman FR editor: Medical management of type 1 diabetes, ed 6, Alexandria, Va, 2012, American Diabetes Association.

4.1.3 Intermediate-acting insulin

The only available intermediate-acting insulin is NPH and is cloudy in form (Table 6).

Intermediate-Acting	Onset of Action	Peak Action	Usual Effective Duration
NPH	2–4 hr	4–10 hr	10–16 hr

Table 6.

Intermediate-acting insulin.

Adapted from Kaufman FR editor: Medical management of type 1 diabetes, ed 6, Alexandria, Va, 2012, American Diabetes Association.

4.1.4 Long-acting insulins

Insulin glargine (Lantus) and insulin detemir (Levemir) are long-acting insulins. Insulin glargine is slow dissolution at the injection site, resulting in a relatively constant and peakless delivery over 24 hours. it is usually given at bedtime. However, it can be given before any meal, but, whichever time is chosen, it must be given constantly at that time. Insulin determir is absorbed relatively quickly from the subcutaneous tissue and then binds to albumin in the bloodstream, resulting in a lengthy action time of approximately 17 hours. Generally, it is given twice a day. It decreases the chances of nocturnal hypoglycemia (Table 7).

Long-Acting	Onset of Action	Peak Action	Usual Effective Duration
Insulin glargine (Lantus)	2–4 hr	Peakless	20–24 hr
Insulin determir (Levemir)	0.8–2 hr. (dose dependent)	Peakless	12–24 hr. (dose dependent)

Table 7.

Long-acting insulin.

Adapted from Kaufman FR editor: Medical management of type 1 diabetes, ed 6, Alexandria, Va, 2012, American Diabetes Association.

4.1.5 Premixed insulin

Premixed insulins are fixed component preparations of rapid or short-acting and intermediate- or long-acting insulins for both fasting and postprandial glycemic control [9]. Persons using premixed insulins must eat at specific times and be consistent in saccharide intake to prevent hypoglycemia (Table 8).

Mixtures	Onset of Action	Peak Action	Usual Effective Duration
70/30 (70% NPH, 30% regular)	0.5–1 hr	Dual	10–16 hr
Humalog Mix 75/25 (75% neutral protamine lispro [NPL], 25% lispro)	<0.25 hr	Dual	10–16 hr
Humalog Mix 50/50 (50% protamine lispro, 50% lispro)	<0.25 hr	Dual	10–16 hr
NovoLog Mix 70/30 (70% neutral protamine aspart [NPA], 30% aspart)	<0.25 hr	Dual	15–18 hr

Table 8.

Premixed insulin.

Adapted from Kaufman FR editor: Medical management of type 1 diabetes, ed 6, Alexandria, Va, 2012, American Diabetes Association.

4.1.6 Insulin regimens

All persons with T1DM need a substitute of insulin that mimics normal insulin action. To mimic normal insulin action, rapid-acting (or short-acting) insulin is given before meals, and this is meant as bolus insulin. Bolus insulin doses are corrected based on the number of saccharide in the meal.

An insulin-to-saccharide ratio can be established for an individual that will guide determinations on the amount of mealtime insulin to infuse. Basal (Long-acting) insulin dose is the amount of insulin required in the post absorptive state to control endogenous glucose output primarily from the liver. Basal insulin also limits lipolysis and the surplus flux of free fatty acids to the liver. These physiologic insulin regimens allow added flexibility in the type and timing of meals.

For normal persons with T1DM, the required insulin dosage is about 0.5 to 1 unit/kg of body mass per day. About half percentage of the total daily insulin dose is used to provide for basal insulin needs. The remainder (rapid-acting insulin) is divided among the meals by giving about 1 to 1.5 units of insulin per 10 to 15 g of saccharide consumed. As a result of the presence of higher level of counterregulatory hormones in the morning, many individuals may require larger doses of mealtime insulin for saccharide consumed at breakfast than for meals later in the day. The type and timing of insulin regimens should be customized based on eating and exercise habits and blood glucose level [1].

4.2 Insulin guidelines

It is often necessary to regulate insulin dosage to prevent hypoglycemia. This occurs most often with moderate to energetic activity lasting more than 45 to 60 minutes. For most persons, a modest decrease (of about 1 to 2 units) in the rapid- (or short-) acting insulin during the period of exercise is a suitable starting point. For lengthy vigorous exercise, a larger decrease in the total daily insulin dosage may be essential. After exercise, insulin dosing also may have to be reduced [1].

4.3 Insulin substitution therapy

Insulin replacement therapy, also referred to as intensive insulin therapy or basal-bolus therapy, is a comprehensive approach to helping patients achieve optimal blood glucose control by mimicking the physiologic delivery of insulin. This approach uses current understanding of factors affecting glucose homeostasis to permit patients to use flexible insulin dosing to match their lifestyles and preferences.

For Type 1 diabetes, a basal-bolus regimen with a long-acting analog and a short- or rapid-acting insulin analog is the most physiologic insulin regimen and the best option for optimal glycemic control [10].

4.3.1 Diabetes technology

Diabetes technology is described as the hardware, devices, and software that people with diabetes use to help manage their condition, from lifestyle to blood glucose levels. Traditionally, diabetes technology has been divided into two main classes: insulin administered by syringe, pen, or pump, and continuous glucose monitor (CGM). More recently, diabetes technology has gotten bigger to include hybrid devices that both monitor glucose and deliver insulin, some automatically, as well as software that serves as a medical device, providing diabetes self-management support [11].

1. Self-Monitoring of Blood Glucose (SMBG)

   People who are on insulin using SMBG should be inspired to test when appropriate based on their insulin regimen. This may include testing when fasting, preceding meals and snacks, at bedtime, before exercise, when low blood glucose is suspected, after treating low blood glucose until they are normoglycemic, and earlier and while performing critical tasks.

   When suggesting SMBG, ensure that patients gather ongoing instruction and regular evaluation of technique, results, and their ability to use data, including uploading/sharing data (if applicable), from SMBG devices to adjust therapy. SMBG is especially significant for insulin-treated patients to monitor for and avoid hypoglycemia and hyperglycemia. A database study on children and adolescents with type 1 diabetes presented that, after adjustment for multiple confounders, increased daily frequency of SMBG was significantly associated with lower A1 [11].

2. Continuous Glucose Monitoring Devices (CGM)

   People using CGM devices need to have the ability to perform self-monitoring of blood glucose to calibrate their monitor and/or verify readings if discordant with their symptoms. For optimal CGM device operation and ongoing use, robust diabetes education, training, and support are required. There are two basic types of CGM devices: those that are owned by the user, un-blinded, and intended for frequent/continuous use, and those that are owned and applied in/by the clinic, which provides data that is blinded or unblended for a discrete period (professional CGM). Table 9 provides the definitions for the types of CGM devices [11].

Type of CGM	Description
Real-time CGM (rtCGM)	CGM systems that measure and display glucose levels continuously
Intermittently scanned CGM (isCGM)	CGM systems that measure glucose levels continuously but only display glucose values when swiped by a reader or a smartphone
Professional CGM	CGM devices that are placed on the patient in the provider’s office (or with remote instruction) and worn for a discrete period of time (generally 7–14 days). Data may be blinded or visible to the person wearing the device.; The data are used to assess glycemic patterns and trends. These devices are not fully owned by the patient - they are a clinic-based device, as opposed to the patient-owned rtCGM/isCGM devices.

Table 9.

Continuous glucose monitoring (CGM) devices.

When used properly, real-time continuous glucose monitors in conjunction with multiple daily injections and continuous subcutaneous insulin infusion, and other forms of insulin therapy is a valuable tools to lower and/or retain A1C levels and/or reduce hypoglycemia in adults and youth with diabetes.

When used properly, intermittently scanned continuous glucose monitors in conjunction with multiple daily injections and continuous subcutaneous insulin infusion and other forms of insulin therapy can be useful and may drop A1C levels and/or decrease hypoglycemia in adults and youth with diabetes to replace self-monitoring of blood glucose.

The use of professional CGM and/or intermittent real-time or intermittently scanned CGM can be helpful in identifying and correcting patterns of hyper- and hypoglycemia and improving A1C levels in people with diabetes on noninsulin as well as basal insulin regimens [11].

5. Diet-planning strategies

Dietitians offer several diet planning stratagems to help diabetic people for maintaining glycemic control. These stratagems emphasize control of saccharide intake and portion sizes. People using intensive insulin therapy must learn to match insulin injections with meals and to match insulin dosages to saccharide intake.

The first step is to determine an appropriate saccharide intake and suitable distribution pattern; an example is shown in Table 9. With the help of nutrition assessment, a person’s usual energy and saccharide intake are estimated. Frequent monitoring of blood glucose levels can help determine whether additional saccharide restriction would be helpful [12]. We cannot consider a food’s glycemic index without taking the glycemic load into account (Table 10).

Meals	Saccharide Allowance
	Grams	Portions(15 g carbohydrate)
Breakfast	60	4
Lunch	60	4
Afternoon snack	30	2
Evening snack	30	2
Dinner	75	5
Totals	255 g	17

Table 10.

Sample saccharide distribution for 8373.6 KJ.

The sample given in Table 9 illustrates a meal pattern for a person consuming 8373.6 KJ (2000 Kcal) daily with a saccharide allowance of 50% of KJ.

$$\mathrm{\text{Calculation: 50\%}}\times \mathrm{\text{2000 Kcal}}=250\mathrm{\text{g saccharide per day}}$$

$$\mathrm{\text{1000Kcal of saccharide}}÷4\mathrm{\text{kcal/g saccharide}}=250\mathrm{\text{g saccharide per day}}$$

$$250\mathrm{\text{g saccharide}}÷15\mathrm{\text{g}}\left(\mathrm{\text{1 saccharide portion}},=,\mathrm{\text{16.7 saccharide portions per day}}\right)$$

Secondly, in type 1 diabetes, the insulin regimen must manage with the individual’s dietary and lifestyle choices. People using conventional insulin treatment must maintain a consistent saccharide intake from day to day to tally their particular insulin prescription, whereas those using intensive therapy can adjust insulin dosages when carbohydrate intakes change.

Saccharide counting can be done either by counting the grams of saccharide provided by foods or by counting saccharide portions, expressed in terms of servings that contain approximately 15gm each. Appendix 1 shows the serving size of different foods group containing 15gm saccharide, which is one saccharide count. One person learned the basic saccharide counting method, individuals can select whatever foods they wish as long as they do not exceed their saccharide goals.

Sample menu for type 1 diabetic people done by translating saccharide portions into day’s meals (Table 11).

Sample menu
Foods	Carbohydrate Portions
Breakfast: Carbohydrate goal = 4 portions or 60 g
3/4c unsweetened, ready-to-eat cereal	1
1/2 c low-fat milk	½
1 scrambled egg	_
1 slice whole-wheat toast (with margarine or butter)	1
170 g orange juice	1 ½
Lunch: Carbohydrate goal = 4 portions or 60 g
2/3 c cooked rice	2
Red gram, dal (raw wt. 30 g)	1
vegetables combination (including carrots, broccoli, and/or dark green leafy)cooked, made with oil; 125 g	1/2
Cucumber salad; 100 g	1/2
Afternoon snack: Carbohydrate goal = 2 portions or 30 g
2 sandwich cookies	1
1 medium apple	1
Dinner: Carbohydrate goal = 5 portions or 75 g
3 chapati (Raw weight flour = 70 g)	3
Palak-paneer (Paneer-50 g; Spinach-100 g)	½
Red gram, dal (raw wt. 30 g)	1
½ small baked potato (with margarine or butter)	½
Bed-time snack: Carbohydrate goal = 2 portions or 30 g
1 c low-fat millk	1
1 slice whole-wheat toast	1

Table 11.

Translating saccharide portions into a Day’s meals.

6. Sick day guidelines/enteral feeds

It is extremely important to educate individuals with type 1 diabetes and their caretakers about the signs and symptoms of a sick day and its management. If sick days are neglected or not managed well it can result in hyperglycemia, hypoglycemia, diabetic ketoacidosis (DKA), hyperosmolar hyperglycaemic state (HHS), or any adverse effect leading to hospital admission. More than hypoglycemia, hyperglycemia and diabetic ketoacidosis are the major causes of hospital admissions during acute illness.

6.1 Principles for sick day management for individuals with type 1 diabetes

• Diabetes medications (insulin/oral agents) must never be stopped. However, it needs to be adjusted based on blood glucose level.

• It is advisable to frequently monitor blood glucose level every two or three hours including at night.

• If blood glucose is >14 mmol/L, check ketones.

• If blood glucose is 15–20 mmol/L with or without ketosis, it is advisable to give 10–20% of the total daily insulin dose (or 0.1 units/kg body mass) as short-or rapid-acting insulin analogue every 2 to 4 hours until blood glucose falls to <15 mmol/L.

• Eating and drinking can be a challenge during sick days. Include food that is easy on the stomach such as rice and curd, and khichdi. If these foods are also difficult to digest, include liquids that contain Saccharide. Aim for 15 grams of saccharide every three to four hours. This may include food containing saccharide like fruit juice, pudding, and fruit-flavored yogurt to prevent hypoglycemia and also maintain some caloric intake.

• In case of hypoglycemia i.e. blood glucose <3.88 mmol/L, reduce insulin dosage by 20 to 50%. In case of severe hypoglycemia where a child is also unconscious or having fits or completely incapable of taking glucose orally, glucagon injection may be useful in reversing the symptoms of hypoglycemia.

• A standard enteral formula (50% saccharide) or a lower-saccharide (33—40% saccharide) formula may be used in individuals with diabetes. At least 30% of total energy should be given as lipid. Drinking adequate amounts of fluids and ingesting saccharide are important [5].

7. Non-nutritive sweeteners

Lowered calorie sweeteners permitted by the Food and Drug Administration (FDA) include sugar alcohols (erythritol, sorbitol, mannitol, xylitol, isomalt, lactitol, and hydrogenated starch hydrolysates) and tagatose. They deliver a lower glycemic response and contain, on average, 2 calories per gram. Sugar alcohols produce a decreased postprandial glucose response than sucrose or glucose and have lower accessible energy but need to be used with carefulness in TIDM children since they can lead to osmotic diarrhea. Sugar alcohols are partly absorbed, hence only half of the Saccharide from sugar alcohols contributes to total saccharide intake [5]. FDA approved sweeteners list is listed in Table 12.

FDA approved Sweeteners	Accepted daily intake (ADI) (mg/kg body mass)
Sucralose	5 mg/kg body mass/day
Aspartame	50 mg/kg body mass/day
Acesulfame K; (Contraindicated in hyperkalemia)	15 mg/kg body mass/day
Saccharin; (Contraindicated in Pregnancy)	5 mg/kg body mass/day
Steviol glycosides	4 mg/kg body mass/day
Siraitia grosvenorii Swingle (Luo Han Guo) fruit extracts (SGFE)	Not Specified
Advantame	32.8 mg/kg body mass/day
Neotame	0.3 mg/kg body mass/day

Table 12.

Common artificial sweeteners.

Source: Adapted from U. S Department of Health and Human Services (2015).

8. Physical activity/exercise

The physical activity comprises bodily movement fabricated by the tightening of skeletal muscles that requires energy expenditure in surplus of resting energy expenditure. Exercise is a subsection of physical activity: planned, structured, and repetitive bodily movement executed to improve or maintain one or more components of physical fitness.

Physical activity should be a vital part of the treatment plan for persons with diabetes. Exercise aids all persons with diabetes improve insulin sensitivity, diminishing cardiovascular risk factors, controlling body mass, and improving well-being.

In persons with T1DM, the glycemic response to exercise varies, contingent on overall diabetes control, plasma glucose, and insulin level at the start of exercise; timing, intensity, and duration of the exercise; previous food intake; and previous conditioning. A significant variable is the level of plasma insulin during and after exercise. Hypoglycemia can arise because of insulin-enhanced muscle glucose uptake by the exercising muscle.

Hypoglycemia is a possible problem associated with exercise in persons taking insulin or insulin secretagogues. Hypoglycemia can ensue during, immediately after, or many hours after exercise. This is because of increased insulin sensitivity after exercise and the need to supply liver and muscle glycogen, which can take up to 24 to 30 hours.

Hyperglycemia also can consequence from the exercise of high intensity, likely because of the effects of counterregulatory hormones. When a person exercises at what for him or her is a high level of exercise strength, there is a greater-than-normal increase in counterregulatory hormones. As a result, hepatic glucose release beats the rise in glucose use. The raised glucose level also may spread into the post-exercise state. Hyperglycemia and worsening ketosis also can consequence in persons with T1DM who are deprived of insulin for 12 to 48 hours and are ketotic. Vigorous activity should be escaped in the presence of ketosis [2]. It is not, however, necessary to delay exercise based simply on hyperglycemia, provided the individual senses well and urine and/or blood ketones are negative. High-intensity exercise is more likely to be the reason for hyperglycemia than insulin deficiency.

8.1 Exercise guidelines

8.2 Saccharide for insulin or insulin Secretagogue users

Through moderate-intensity exercise, glucose uptake is increased by 8 to 13 g/hr.; this is the basis for the suggestion to add 15 g of saccharide for every 30 to 60 minutes of activity (depending on the intensity) over and above normal practices. Moderate exercise for less than 30 minutes usually does not need any additional saccharide or insulin adjustment, unless the individual is hypoglycemic earlier than the start of exercise. Added Saccharide should be consumed if pre-exercise glucose level are less than 5.6 mmol/L.

For the exerciser with diabetes whose blood glucose level may plunge sooner and lower than the exerciser without diabetes, feeding saccharide after 40 to 60 minutes of exercise is significant and also may support in preventing hypoglycemia. Drinks comprising 6% or less of saccharide empty from the stomach as quickly as water and have the advantage of providing both needed fluids and Saccharide. Consuming Saccharide immediately after exercise improves the repletion of muscle and liver glycogen stores. For the exerciser with diabetes, this takes on added value because of the increased risk for late-onset hypoglycemia [1].

9. Exchange lists for diabetes

The exchange system sorts foods into groups by their proportions of carbohydrate, fat, and protein. Each food list comprises foods grouped together because they have similar nutrient content and serving sizes. Then any food on a list can be “exchanged” for any other on that same list. Foods on the Starch list, Fruits list, Milk list, and Sweets, Desserts, and Other Carbohydrates list are similar because they contain 12 to 15 grams of carbohydrate per serving.

9.1 Serving sizes

The serving sizes have been carefully adjusted and defined so that a serving of any food on a given list provides roughly the same amount of carbohydrate, fat, and protein, and, therefore, total energy. Any food on a list can thus be exchanged, or traded, for any other food on the same list without significantly affecting the diet’s energy-nutrient balance or total kilocalories [12]. Foods are listed with their serving sizes, which are usually measured after cooking. When you begin, measuring the size of each serving will help you learn to “eyeball” correct serving sizes [1]. The amounts of nutrients in one serving from each list are shown in Appendix 2.

10. Conclusion

Type 1 diabetes is a condition in which pancreatic beta-cell get destructed and leads to absolute insulin deficiency. Lack of insulin causes hyperglycemia, polyuria, polydipsia, polyphagia, body mass loss, dehydration, electrolyte disturbance, and ketoacidosis. MNT necessitates an individualized tactic and effective nutrition self-management education, recommendation, and support. A key component of MNT is the provision of adequate calories for normal growth and development for children and adolescents with T1DM. The patient should monitor their saccharide intake either through saccharide counting or meal planning exchange lists for flexibility and variety in meals. Saccharide intake from whole grains, vegetables, fruits, legumes, and dairy products, with an emphasis on foods higher in fiber and lower in glycaemic load, should be advised over other sources, especially those containing sugars. Saccharide counting is helpful for people with diabetes in managing blood glucose level by tracking the grams of saccharide consumed at meals. All persons with T1DM need a substitute of insulin that mimics normal insulin action. An insulin-to-saccharide ratio can be established for an individual that will guide determinations on the amount of mealtime insulin to infuse.

Glycemic index and glycemic load of selected foods.

FOODS	GI	GL
Grains
Buckwheat	54	16
Rice, Basmati	58	22
Rice, Brown	50	16
White bread (avg)	70	10
Whole wheat bread (avg)	77	9
Oatmeal	55	12
Vegetables
Carrots (avg)	47	3
Peas (green, avg)	48	3
Potato, baked (avg)	85	26
Potato, boiled	88	16
Potato, French fries	75	22
Potato, microwaved	82	27
Pumpkin	75	3
Sweet corn	60	11
Sweet potato (avg)	61	17
Yam (avg)	37	13
Legumes
Baked beans (avg)	48	7
Broad beans	79	9
Chickpeas (avg)	28	8
Kidney beans (avg)	28	7
Lentils (avg)	29	5
Soy beans (avg)	18	1
Fruit
Apple (avg)	38	6
Apricot (dried)	31	9
Banana (avg)	51	13
Cherries	22	3
Grapes (avg)	46	8
Kiwi fruit (avg)	53	6
Mango	51	8
Orange (avg)	48	5
Papaya	59	10
Peach, fresh (avg)	42	5
Pear (avg)	38	4
Pineapple	59	7
Raisins	64	28
Watermelon	72	4
Dairy Foods
Milk, full fat	27	3
Milk, skimmed	32	4
Milk, condensed	61	33
Custard	43	7
Ice cream, regular (avg)	61	8
Yogurt, low fat	33	10
Beverages
Apple juice	40	12
Coca Cola	63	16
Fanta	68	23
Orange juice (avg)	52	12
Snack Foods
Fish sticks	38	7
Peanuts (avg)	14	1
Popcorn	72	8
Potato chips	57	10
Sugars
Honey (avg)	55	10
Fructose (avg)	19	2
Glucose	100	10
Lactose (avg)	46	5
Sucrose (avg)	68	7

From Brand Miller J et al.: The new glucose revolution, New York, 2003, Avalon/Marlowe & Company.

The following chart shows the amount of nutrients in one serving from each list.

STARCH LIST

The Starch list includes bread, cereals and grains, starchy vegetables, crackers and snacks, and legumes (dried beans, peas, and lentils).

1 starch choice = 15 grams carbohydrate, 0–3 grams protein, 0–1 grams fat, and 334.72 KJ.

1 starch is:

1/2 cup of cooked cereal, grain, or starchy vegetable

1/2 cup of cooked rice or pasta

28.35 g of a bread product, such as 1 slice of bread

21.26 to 28.35 g of most snack foods (some snack foods may also have extra fat)

Note: 1 OZ equal to 28.35gm, 1cup(metric) equal to 250 ml.

Food	Serving Size	Food	Serving Size
Bread		Cereals and Grains
Reduced-calorie*	2 slices, (42.5 g)	Barley, cooked	1/3 cup
White, whole-grain, pumpernickel, rye, unfrosted raisin	1 slice, (28.35 g)	Bran, dry, Oat*	1/4 cup
Chapatti, small, 6 inches across	1	Bran, dry,Wheat*	1/2 cup
Cornbread, 1 3/4 inch cube†	1, (42.5 g)	Bulgar (cooked)*	1/2 cup
English muffin	1/2	Cereals
Hot dog bun or hamburger bun	1/2, (28.35 g)	Rice,milled	1/2 cup
Naan, 8 inches by 2 inches	1/4	Wheat, semolina	1/2 cup
Pancake, 4 inches across, 1/4 inch thick	1	Bran*	1/2 cup
Pita, 6 inches across	1/2	Cooked (oats, oatmeal)	1/2 cup
Roll, plain, small	1 (28.35 g)	Puffed	1 1/2 cup
Stuffing, bread†	1/3 cup	Shredded wheat, plain	1/2 cup
Taco shell, 5 inches across†	2	Sugar-coated	1/2 cup
Tortilla, corn, 6 inches across	1	Unsweetened, ready-to-eat	3/4 cup
Tortilla, flour, 6 inches across	1	Couscous	1/3 cup
Tortilla, flour, 10 inches across	1/3 tortilla
Waffle, 4-inch square or 4 inches across†	1
Granola		Crackers and Snacks
Low-fat	1/4 cup	Animal crackers	8
Regular†	1/4 cup	Crackers
Grits, cooked	1/2 cup	Round-butter type†	6
Kasha	1/2 cup	Saltine-type	6
Millet, cooked	1/3 cup	Sandwich-style, cheese or peanut butter filling† 3	3
Muesli	1/4 cup	Whole-wheat regular†	2–5 (21.26 g)
Pasta, cooked	1/3 cup	Whole-wheat lower fat or crispbreads*	2–5 (21.26 g)
Polenta, cooked	1/3 cup	Graham cracker, 21/2-inch square	3
Wheat germ, dry	3 Tbsp	Matzoh	21.26 g
Wild rice, cooked	1/2 cup	Melba toast, about 2-inch by 4-inch piece	4 pieces
Starchy Vegetables		Oyster crackers	20
Cassava	1/3 cup	Popcorn (Microwave Popped)	3 cups
Corn	1/2 cup	With butter†*	3 cups
On cob, large	1/2 cob (141.75 g)	No fat added*	3 cups
Hominy, canned*	3/4 cup	Lower fat*	3 cups
Mixed vegetables with corn, peas, or pasta* 1 cup	1 cup	Pretzels	21.26 g
Parsnips* 1/2 cup	1/2 cup	Rice cakes, 4 inches across	2
Peas, green* 1/2 cup	1/2 cup	Snack Chips
Plantain, ripe 1/3 cup	1/3 cup	Fat-free or baked (tortilla, potato), baked pita chips	15–20 (21.26 g)
Potato		Regular (tortilla, potato)†	9–13 (21.26 g)
Baked with skin	1/4 large (85.05 g)	Beans, Peas, and Lentils; The Choices on this List Count as 1 Starch + 1 lean meat.
Boiled, all kinds	1/2 cup or 1/2 medium (85.05 g)	Baked beans*	1/3 cup
Mashed, with milk and fat†	1/2 cup	Beans, cooked (black, garbanzo,kidney, lima, navy, pinto, white)*	1/2 cup
French fried (oven-baked)	1 cup (56.7 g)	Lentils, cooked (brown, green, yellow)*	1/2 cup
Pumpkin, canned, no sugar added*	1 cup	Peas, cooked (black-eyed, split)*	1/2 cup
Spaghetti/pasta sauce	1/2 cup	Refried beans, canned‡*	1/2 cup
Squash, winter (acorn, butternut)*	1 cup
Succotash*	1/2 cup
Yam, sweet potato, plain 1/2 cup	1/2 cup

*

More than 3 grams of dietary fiber per serving.

†

Extra fat, or prepared with added fat. (Count as 1 starch +1 fat).

‡

480 milligrams or more of sodium per serving.

Note: 1cup(metric) equal to 250 ml.

FRUITS LIST

The Fruits list includes fresh, frozen, canned, and dried fruits and fruit juices. 1 fruit choice = 15 grams carbohydrate, 0 grams protein, 0 grams fat, and 251.04 KJ.

In general, 1 fruit choice is:

1/2 cup of canned or fresh fruit or unsweetened fruit juice

1 small fresh fruit (113.4 g)

2 tablespoons of dried fruit

NOTE: The weight listed includes skin, core, seeds, and rind; 1cup(metric) equal to 250 ml.

Food	Serving Size	Food	Serving Size
Fruit		Orange, small*	1 (184.27 g)
Apple, unpeeled, small	1 (113.4 g)	Papaya	1/2 fruit or 1 cup cubed (226.8 g)
Apples, dried	4 rings	Peaches
Applesauce, unsweetened	1/2 cup	Canned	1/2 cup
Apricots		Fresh, medium	1 (170.1 g)
Canned	1/2 cup	Pears
Dried	8 halves	Canned	1/2 cup
Fresh*	4 whole (155.92 g)	Fresh, large	1/2 (113.34 g)
Banana, extra small	1 (113.4 g)	Pineapple
Blackberries*	3/4 cup	Canned	1/2 cup
Blueberries	3/4 cup	Fresh	3/4 cup
Cantaloupe, small	1/3 melon or 1 cup cubed (311.85 g)	Plums
Cherries	2	Canned	1/2 cup
Sweet, canned	1/2 cup	Dried (prunes)	3
Sweet fresh	12 (85.05 g)	Small	2 (141.75 g)
Dates	3	Raspberries*	1 cup
Dried fruits (blueberries, cherries, cranberries, mixed fruit, raisins)	2 Tbsp	Strawberries*	1 1/4 cup whole berries
Figs		Tangerines, small*	2 (226.8 g)
Dried	1 1/2	Watermelon	1 slice or 11/4 cups cubes (382.72 g)
Fresh*	1 1/2 large or 2 medium (99.22 g)	Fruit Juice
Fruit cocktail	1/2 cup	Apple juice/cider	1/2 cup
Grapefruit		Fruit juice blends, 100% juice	1/3 cup
Large	1/2 (311.85 g)	Grape juice	1/3 cup
Sections, canned	3/4 cup	Grapefruit juice	1/2 cup
Grapes, small	17 (85.05 g)	Orange juice	1/2 cup
Honeydew melon	1 slice or 1 cup cubed (283.5 g)	Pineapple juice	1/2 cup
Kiwi*	1 (99.22 g)	Prune juice	1/3 cup
Mandarin oranges, canned	3/4 cup
Mango, small	1/2 fruit (155.9 g) or 1/2 cup
Nectarine, small	1 (141.75 g)

*

More than 3 grams of dietary fiber per serving.

MILK LIST

The Milk list groups milks and yogurts based on the amount of fat they have (fat-free/low fat, reduced fat, and whole).

Cheeses are on the Meat and Meat Substitutes list (because they are rich in protein).

Cream and other dairy fats are on the Fats list.

NOTE: In general, one milk choice is 1 cup (8 fluid ounces or ½ pint) milk or yogurt.

Food	Serving Size
Fat-free or low-fat (1%); 1 fat-free/low-fat milk choice = 12 g carbohydrate, 8 g protein, 0–3 g fat, and 418.4 KJ.
Milk, buttermilk, acidophilus milk, Lactaid	1 cup
Evaporated milk	½ cup
Yogurt, plain or fl avored with an artifi cial sweetener	2/3 cup (170.1 g)
Reduced-fat (2%); 1 reduced-fat milk choice = 12 g carbohydrate, 8 g protein, 5 g fat, and 502. 08 KJ.
Milk, acidophilus milk, kefi r, Lactaid	1 cup
Yogurt, plain	2/3 cup (170.1 g)
Whole; 1 whole milk choice = 12 g carbohydrate, 8 g protein, 8 g fat, and 669.44 KJ.
Milk, buttermilk, goat’s milk	1 cup
Evaporated milk	½ cup
Yogurt, plain	226.8 g

Note: 1cup(metric) equal to 250 ml.

Dairy-Like Foods
Food	Serving Size	Count as
Chocolate milk
fat-free	1 cup	1 fat-free milk +1 carbohydrate
whole	1 cup	1 whole milk +1 carbohydrate
Eggnog, whole milk	½ cup	1 carbohydrate +2 fats
Rice drink
flavored, low fat	1 cup	2 carbohydrates
plain, fat-free	1 cup	1 carbohydrate
Smoothies, flavored, regular	283.5 g	1 fat-free milk +2½ carbohydrates
Soy milk
light	1 cup	1 carbohydrate + ½ fat
regular, plain	1 cup	1 carbohydrate +1 fat
Yogurt
and juice blends	1 cup	1 fat-free milk +1 carbohydrate
low carbohydrate (less than 6 grams carbohydrate per choice)	2/3 cup (170.1 g)	½ fat-free milk
with fruit, low-fat	2/3 cup (170.1 g)	1 fat-free milk +1 carbohydrate

Note: 1cup(metric) equal to 250 ml.