Educating Your Patients On Nutrition And Exercise

Author(s): 
By Pamela M. Jensen, DPM

Diet and exercise are essential for blood sugar management and are subject of much frustration for the diabetic patient and the physician. With each visit to the physician’s office, the patient has to anticipate the stern lecture about exercising, controlling his or her diet, abstaining from sweets, and testing his or her sugars regularly or face the multitude of complications from diabetes. In addition, physicians may also give a patient a handout with the recommendations from the American Diabetes Association.
But does this method work? King and Armstrong studied the effectiveness of this type of program and followed a cohort of chronic dieters who see a doctor and are told to lose weight. They found that half of all these patients actually gained weight. The conclusion of this study and years of experience was twofold: deprivation invites bingeing and diets don’t work.

So what is the solution? Lifestyle modification. This includes a balanced diet with moderate physical activity. The Diabetes Prevention Program is a 27-center randomized clinical trail that studied more than 3,200 adults who were 25 years or older and who were at increased risk of developing type 2 diabetes. This was the first major clinical trial to show that lifestyle changes in diet, exercise and loss of a little weight can prevent or delay the progression of the disease. This study evaluated the effectiveness of intensive lifestyle modification, including healthy diet, moderate physical activity of 30 minutes a day five days a week, standard care plus the use of metformin and standard care plus placebo.
Participants who made lifestyle changes reduced their risk of getting type 2 diabetes by 58 percent. A healthy diet and moderate exercise lower blood sugars and improve the body’s use of insulin, and slow progression of the disease and its complications.

Redefining The 'Well-Balanced’ Diet
Most mistakenly believe that a “diabetic diet” means restriction on sugar intake and the need to avoid sugar-containing items such as cakes, cookies and candies. The key words here are “well-balanced” diet. In reality, diabetics can eat anything a non-diabetic can eat as long as it is a well-balanced diet and the carbohydrate intake is spread out through the day. In addition, if the diabetic is taking insulin or oral medication, he or she will want to eat carbohydrates in such a way that the sugar from the meal peaks when the medication is working at its peak.
The Food Pyramid is the best example of a well-balanced diet for the average person as well as the diabetic. On average, Americans eat 40 to 45 percent of the recommended caloric intake of carbohydrates. Grains, beans and starchy vegetables have very little fat, saturated fat or cholesterol. They are also filled with vitamins, minerals and fiber. Vegetables are low calorie and full of vitamins and fiber. A minimum of three servings a day is required.
Fruits should be eaten at least twice a day when blood sugars are low. In addition, eating a whole orange with the pulp and fiber does not increase blood sugars as quickly as concentrated orange juice, enabling the diabetic to have more control over the glycemic response. Low fat options from the milk group will provide calcium to prevent osteoporosis without the saturated fat and cholesterol.
Patients with diabetes need as much protein as anyone else although cutting down on saturated fats and using leaner options will help decrease the diabetic’s already high risk of heart disease. Moderate protein restriction has shown that diabetic patients have increased adiposity and decreased muscle strength.
Sweets should be taken in moderation. Although studies have shown that sugars do not raise blood glucose any higher than carbohydrates upon ingestion, sweets contain little nutritional value.

Convey The Importance Of Fiber
The ADA gives the following recommendations for people with diabetes:
• Limit fat to 30 percent or less of daily calories.
• Limit saturated fat to 10 percent or less of daily calories.
• Limit protein to 10 to 20 percent of daily calories. For those with initial signs of diabetes-induced kidney disease, restrict protein to 10 percent of daily calories.
• Limit cholesterol to 300 milligrams or less daily.
• Consume about 20 to 35 grams of fiber daily.
Fiber, which includes whole grain products, fruits, vegetables and legumes, plays an important role in glycemic control and weight management. The skins on the fruits and vegetables contain the largest amount of fiber and should also be consumed. Fiber is not broken down by the body and is not metabolized into carbohydrates although it is considered one. Therefore, it can be subtracted from the total carbohydrate consumption of what one is eating.
The average American eats half of the recommended 20 to 35 grams of fiber each day. A diabetic who eats greater than 50 grams of fiber a day is able to control blood sugars far better than those who eat less. In addition, fiber adds bulk and makes you feel full, aiding in weight loss. To avoid constipation, remember to drink six to eight glasses of water per a day.

What Vitamins Can Have An Impact For Your Diabetes Patients?
Well-balanced meals and snacks are important in supplying the majority of one’s nutrients. If the diet is not well rounded, a vitamin supplement is not going to make up for large losses of nutrients. In addition, many foods contain beneficial substances that cannot be obtained by a supplement. A vitamin and mineral supplement with no more than 100 to 150 percent of the daily-recommended value (with at least 20 types of vitamins and minerals listed) is appropriate. It should contain 400 mg of folic acid and 400 IU of vitamin D. Men usually do not need a supplement with iron. Store-brand supplements are as good as name-brand supplements.
Vitamin C and E are antioxidants that neutralize free radicals that damage cell and can lead to diseases like cancer, heart disease and lung disease. Vitamin C levels in diabetics are generally lower due to high blood sugar levels, hampering the uptake of Vitamin C by cells. Vitamin C has known influence in aiding control of blood sugar levels as well as control of cholesterol and triglyceride levels. Recommended daily requirement of vitamin E is 30 IU and there is some evidence that it may play a role in preventing kidney and/or eye damage. However, a large dosage greater than 800 IU increases the risk of stroke in those with high blood pressure and interferes with anticoagulants.

Five Key Tips On Exercise
When giving advice to diabetes patients about exercise, consider the following tips.
• If the patient is 35, he or she may need a stress test.
• Emphasize blood glucose testing before and after exercise. These patients should not exercise if blood glucose is over 250 and there are ketones in their urine. If blood glucose is over 250 but no ketones are present, you should follow these guidelines. Tell type 1 patients not to exercise if their blood glucose is 300 or more. Tell type 2 patients not to exercise if their blood glucose is 400 or more.
• Encourage these patients to always carry a carbohydrate snack.
• Encourage them to drink plenty of fluids.
• Emphasize wearing shoes and equipment that fit well.

Final Thoughts
A well-balanced diet combined with exercise can lower the blood sugar and improve the body’s ability to use glucose. A variety of factors influence how quickly food is digested. Meals with large amounts of fiber and raw foods take longer to digest and reduce the degree of blood sugar elevation. With regular exercise, the amount of insulin needed decreases. In addition, a balanced diet with exercise decreases the risk factors for heart disease, improves the control of high blood pressure, facilitates weight loss, aids in relieving depression and increases energy levels.
In conclusion, educating the patient about a proper well-balanced diet and exercise will empower the patient to control his or her blood sugars without feeling guilty and deprived.

Dr. Jensen is a first-year resident at the University of Texas Health Science Center at San Antonio. She gives additional acknowledgement to Kevin A. Lawson, MSN, MPH, PHND.
Dr. Steinberg is an Assistant Professor in the Department of Orthopaedics/Podiatry Service at the University of Texas Health Science Center.




References:

References
1. Knowler WC, Barrett-Connor E, Fowler SE, et al, Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N England Journal of Medicine, 346(6) 2002.J
2. Rich S, Diabetes: A Gentle Approach to a ToughProblem, Radiance Fall 1995.
3. Brodsky IG, Nutritional Effects of Dietary Protein Restriction in Insulin-Dependent Diabetes Mellitus, The Journal of Nutrition, 128:2 Feb 1998.
4. Mokdad AH et al, Diabetes trends in the U.S.: 1990-1998. Diabetes Care 23(9) 2000.
5. National Diabetes Fact Sheet, National Center for Chronic Disease Prevention and Health Promotion, http://www.cdc.gov/diabetes/pubs/estimates.htm
6. Joslin Diabetes Center – Managing Diabetes, http://www.joslin.harvard.edu/education/library
7. Eating Healthy With the Diabetes Food Pyramid As Your Guide, American Diabetes Association.

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