Let's chat about: Power of Nutrition in Diabetes

Alexina Ancheta1 , Nella C. Delva2

1Seton Home Study School

2Florida State University, College of medicine

Abstract

Type 1 Diabetes is an autoimmune disease that destroys the beta cells in the pancreas that make insulin. Type 2 Diabetes is often thought to be the same as Type1 Diabetes, but they are different in nature and treatment. Nevertheless, there are similarities between them. Type 1 and Type 2 Diabetes both occur when the body cannot properly store and use glucose. Type 1 Diabetes occurs when the insulin is no longer produced because the immune system destroys the pancreatic beta cells. On the other hand, Type 2 Diabetes is when the pancreas still produces insulin, but the body cannot use it effectively. The nutritional requirements and recommendations for diabetic patients and non-diabetics are virtually the same. Proper nutrition is required for physical and mental development. The aim of this paper is to evaluate current and past literature through medical journals and articles to provide information to the general population. Different food options, diets, and exercises will be assessed for the prevention of the development of diabetes and for the maintenance and prevention of further complications for type 1 and type 2 diabetics.

Introduction

Diabetes has one of the highest rates of increase in the world. It may be costly and can lead to a greater risk of morbidity and mortality if not controlled. (Ojo et al., 2021) The underlying biology of type 1 dIabetes is difficult to study as the T-cells have been destroying beta cells for a long period by the time the person begins to show symptoms and the initial cause of the disease is unclear. The primary cause of type 1 diabetes is still unknown, but many studies show that genes and environmental factors play a major role in the development. One of the most common metabolic disorders is type 2 diabetes mellitus. It develops when the insulin secretion of pancreatic β-cells is not properly absorbed by insulin-sensitive tissues. It is associated with diet, exercise, and lifestyle. The symptoms are usually the same in both cases of diabetes (tiredness and fatigue, unexplained weight loss, an increased thirst and urination), but the time span is different. Those with type 2 diabetes experience these symptoms over several weeks while those with type 1 diabetes develop these symptoms over time. Both types can lead to complications such as kidney or cardiovascular disease, vision loss, and neurological disorders. According to an International Diabetes Federation report in 2021, there are 537 million adults with diabetes worldwide. Over 1.2 million children and adolescents suffer from type 1 diabetes. A meta-analysis showed that the incidence of type 1 diabetes is 15 for every 100,000 people. (Mobasseri et al., 2020).

According to the World Health Organization, there were around 9 million type 1 diabetics in the world. (World Health Organization, 2021) Unfortunately, research is too limited here in the Philippines that there are not enough studies to conclude the prevalence or incidence. (Tan, 2015) However, a survey was conducted in Bulacan, Central Luzon Region, Philippines. The results showed a very low prevalence of type 1 diabetes with only 7 children aged 0 - 14 years old from 1989 to 1998 diagnosed with type 1 diabetes.

Nutrition plays a major role in our health. The food choices we make and the amount of physical activity we get contribute to our overall health. Many people just eat without knowing the nutritional content of what they are eating. They do not know whether they are intaking too much or too little of certain nutrients. Poor nutrition may lead to malnutrition, obesity, or various diseases. Food directly affects our blood sugar levels. It is especially important for diabetics to choose the right foods for proper diabetes management. Therefore, it is important to study nutrition to stay healthy, both now and later in life.

Type 1 Diabetes Preclinical Studies

T-cell destruction of the pancreatic, insulin-producing beta cells causes type 1 diabetes, which leads to primary insulin deficiency and a metabolic disorder. (Elso et al., 2019) In order to better understand this disorder, several research studies have been using non-obese diabetic mice (NOD) as models system to research human type 1 diabetes since humans and NOD mice share many similar pathological features. Insulin specific T-cells and proinsulin cause diabetes in the NOD mice, which are similar to type 1 diabetes in humans. (Deltour et al., 1993) Results of this study found that Ins2 protects NOD mice from diabetes as it promotes the genetic deletion of T-cells in the thymus while Ins1 triggers the development of autoimmune diabetes. These findings are important because this study hints at the possibility of possible genetic cure of this autoimmune disorder.

Some drawbacks to the method used in this study important to be addressed are that the expression of human transgenes does not follow the murine orthologue, there is a variability of expression caused by random transgenes, and the expression is subject to environmental factors. (Pathiraja et al., 2014) This paper used adequate genetic tools (CRISPR/Cas 9) to replace expression of human insulin to murine insulin 1. Although human insulin replacement in mice at the murine insulin 1 locus produced human insulin and developed insulitis further protection from diabetes was gained.

Diet and Nutrition

A. Vegetarian Diets

Diabetes is strongly associated with food choices, obesity, and environmental factors, but β-cell dysfunction may also lead to diabetes. (Ohn et al., 2015) Although we may not be able to control β-cell dysfunction, we can control the food we eat. One of the most widely accepted diets that has shown to improve overall health is a diet consisting of fruits and vegetables. (Chiu et al., 2018) There are several different types of vegetarian diets. A vegetarian diet is basically a diet without animal products, but there are multiple sub-groups with certain characteristics. The lacto-ovo vegetarian diet, which is the most common type of vegetarian diet, excludes meat and fishery products but includes milk, eggs, and derivatives. (Tromba et al., 2021) The pesco-vegetarian diet includes fish. The lacto-vegetarian diet excludes eggs while the ovo-vegetarian diet excludes milk. The vegan diet excludes animal by-products such as honey. This is the strictest type of vegetarian diet.

The Tzu Chi Health Study wanted to distinguish the diabetes risk between true vegetarians and those with minimal meat consumption. (Chiu et al., 2018) The results showed that vegetarian diets help prevent certain diseases such as cancer and diabetes, but it also has its drawbacks due to the lack of nutritional content found in other foods. They are rich in carbohydrates, n-6 fatty acids, dietary fiber, carotenoids, folic acid, vitamin C, vitamin E, and magnesium, but low in protein, saturated fat, long-chain n-3 fatty acids, retinol, vitamin B12, iron and Zinc. (Tromba et al., 2021) Furthermore, since vegetarian diets do not contain fish and meat, protein is also eliminated. This leads to higher carbohydrate reliance and consumption, leading to higher insulin dosages for diabetics. Although vegetables contain fiber which stabilizes blood sugar, high intake of fiber may hinder the absorption of some important minerals such as iron, zinc, and calcium. Large intake of fruits means high intake of fructose, which may lead to obesity and insulin resistance. This is important information because type 1 diabetic patients need to adjust insulin dosages, and it is advisable that they eat fruits that are less ripe and with less sugar content.

B. Water

According to the Mediterranean Diet, water should be taken every meal with a minimum of two liters per day. Water is very important in a healthy diet. Lack of water leads to a weak immune system and decrease in physical efficiency, which leads to diseases. Flavored water and other artificial beverages should be avoided. (Krzyśko-Łupicka et al., 2016) Not only do they not have much nutritional benefit but they also contain excess sugars and preservatives.

C. Fruits

Fruits are also important in our diet because they provide us with vitamins and aid in protection against various diseases. (Mańkiewicz-Żurawska et al., 2019) However, fruits belong to the rapidly absorbed carbohydrates group. Thus, they should be eaten in ample amounts.The World Health Organization suggests that fruit intake does not exceed 300g per day. Berries are recommended for diabetics because they contain minimal sugar and high water and dietary fiber content. Fiber is vital in keeping our immune system healthy, reducing blood glucose and cholesterol, and improving the flow of nutrients in the intestines. A seven-year study on 2,100 type 1 diabetes patients by Schoenaker showed that an additional 5g of fiber a day significantly reduced the risk of cardiovascular diseases. (Schoenaker et al., 2012)

D. Fats

Fats have the highest calorific value and provide us with essential vitamins and fatty acids. (Mańkiewicz-Żurawska et al., 2019) They are responsible for the development of organs and tissues. Fats are grouped into saturated and unsaturated fats. Saturated fats come from animal products, while unsaturated fats come from plant products. Studies show that unsaturated fats are more beneficial than saturated fats as they help maintain normal cholesterol levels, reducing the risk of diabetes and cardiovascular diseases. (O’Reilly et al., 2009)

Table 1: Nutritional Table of Common Food

Food	Serving size	Carbohydrates	Fats	Calories
White Steamed Rice	0.5 cup	22g	0g	100
Peeled baked potatoes	1 medium	34g	0g	145
White Bread	1 slice	12g	1g	66
Cereal, Basic 4	1 cup	44g	2g	200
Chicken breast - broiler/fried/grilled	1 piece	0g	3g	142
Pork - ribs, spareribs, braised	3 ounces	0g	26g	338
Beef - corned, cured, canned, slices	3 ounces	0g	13g	213
Tuna, light, w/oil, drained	3 ounces	0g	7g	158
Fresh crisphead lettuce	1 cup	2g	0g	10
Whole milk	1 cup	12g	8g	149
Fresh orange juice	1 cup	26g	0g	112
Fresh banana	1 medium piece	27g	0g	105
Fresh apple	1 medium piece	25g	0g	95
Milk chocolate bar	1 ounce	14g	9g	142
Vanilla ice cream	0.5 cup	16g	7g	137

Source: Nourish by WebMD, March 2022

The table above lists common food from the different food groups with their respective

carbohydrates, fats, and calories per serving portion.

Table 2: Healthy Food Alternatives

Food	Serving size	Carbohydrates	Fats	Calories
Brown rice - cooked/boiled	0.5 cup	22g	1g	108
Peeled potatoes - cooked/boiled	0.5 cup	16g	0g	67
Wheat bread	1 slice	14g	1g	78
Cereals, Corn Flakes	1 cup	24g	0g	102
Quaker instant oatmeal	1 Individual Pack	27g	3g	150
Center loin roast pork braised	3 ounces	0g	11g	196
Tuna, light, w/water, drained	3 ounces	0g	3g	109
Nonfat milk	1 cup	12g	0g	86
Dark chocolate bar	1 ounce	15g	10g	142
Plain low-fat yogurt	0.5 cup	9g	2g	77

Source: Nourish by WebMD, March 2022

The table above provides healthier food alternatives that provide the necessary energy and

nutrients without excess sugars, sodium, and fats. However, it is still important to have a

balanced diet by eating a variety of foods.

Carbohydrates and Carbohydrate Counting

Carbohydrates increase the blood sugar level but should not be limited to ensure sufficient energy and nutrient intake. Adjusting the insulin dosage through carbohydrate counting is important to balance the insulin and carbohydrate ratio. The bolus insulin dose is obtained from the number of carbohydrates in each meal.and the insulin-to-carbohydrate ratio. (Gillespie et al., 1998) It is important that the type 1 or type 2 diabetes patient as well as the family take an educational program with experienced professionals on carbohydrate counting and healthy eating habits to accurately manage diabetes.

The American Academy of Nutrition and Dietetics has identified three levels of carbohydrate

counting as follows:

● Level 1 — Diabetic patients should know that carbohydrates raise blood sugar levels.

They are encouraged to eat around the same amount of carbohydrates each meal. They

should learn the basic methods to quantify carbohydrates: gram increments of

carbohydrates, 10–12 g carbohydrate portions, and 15 g carbohydrate exchanges. This

level is particularly helpful for patients undergoing treatment with insulin doses twice a

day and for those who require consistent carbohydrate intake.

● Level 2 — This intermediate step focuses on pattern management, where patients learn

to evaluate blood sugar level changes compared to carbohydrate consumption. Factors

to consider are physical activity and insulin. Patients who are knowledgeable in this step

have the ability to change their insulin-to-carb-ratio and carbohydrate intake under the

supervision of pediatric diabetes teams.

● Level 3 — In this stage, advanced carbohydrate counting, patients on multiple daily

injections or continuous subcutaneous insulin pumps have a firm understanding of

insulin-to-carb-ratio and can use it efficiently. (Kawamura, 2007)

Each patient has a different insulin-to-carb-ratio, and it can vary throughout the day. This ratio tends to be higher in the morning, lower for lunch, and higher in the evening. (Danne et al., 2006) As opposed to adolescents, adults have more stable insulin-to-carb-ratio as the body adjusts over time and have more fixed routines of daily activities.

Table 3: Insulin - Carbohydrate Computation Sample

Food	Serving	Carbohydrate
Brown rice - cooked/boiled	0.5 cup	22g
Chicken breast - broiler/fried/grilled	1 piece	0g
Fresh crisphead lettuce	0.5 cup	1g
Fresh apple	1 medium piece	25g
Nonfat milk	1 cup	12g
		70g

Source: Nourish by WebMD, March 2022

This insulin-carbohydrate ratio is the ratio of the insulin units to the number of carbohydrates. In the example above, the insulin-carbohydrate ratio is 1:10, one unit of insulin for every ten carbohydrates. Other common rations include 1:5, 1:8, 1:12, and 1:15. This varies from patient to patient depending on different factors such as metabolic rate. To compute the total number of insulin units needed, add up the number of carbohydrates to be eaten then divide it by the number to the right of the colon, which is 10 in the example. 70 divided by 10 equals 7. Thus, the total insulin units required for the meal is 10.

Exercise

Exercise is a key component in the prevention and management of diabetes. There are many types of exercise, but we’ll only discuss a couple. Low to moderate intensity exercise often leads to hypoglycemia, while high intensity exercise may result in hyperglycemia. (Lumb et al., 2014) Nevertheless, exercise is important because it reduces the risk of cardiovascular disease and improves metabolic profiles among others. Therefore, daily exercise will make a positive difference in diabetic health.

 An interesting fact is that type 1 diabetics exercise less than the general population. (Colberg et al., 2015) One of the main concerns of exercise in type 1 diabetes patients is the risk of hypoglycemia. (Brazeau et al., 2008) Hypoglycemia may occur during the activity or up to 24 hours after. (Burr et al., 2012) Among the patients who exercise, they usually keep their sugar high during the activity by eating before or during exercise which leads to increased energy intake and consequent weight gain. (Francescato et al., 2015) However, exercise is also important to prevent obesity, decrease cardiovascular risk and mortality, and keep our bodies healthy. (Chimen et al., 2012) Incorporating exercise into a weight loss plan leads to greater loss of fat mass and lean muscle preservation. (Miller et al., 2013) There is no set type, time, or intensity of physical activity. Resistance training reduces fat but has minimal effect on overall weight loss. A study showed that aerobic exercise lowers visceral adipose tissue to a greater extent than progressive resistance training, but resistance exercise preserves more lean muscle which is much needed by the body. (Ismail et al., 2012) High-intensity and moderate-intensity exercises do not show significant differences in weight loss. (Swift et al., 2014) High-intensity exercise may even lead to fluctuating blood sugar drops and spikes. Therefore, it is highly recommended that type 1 diabetics do regular physical activity in small portions. (Riddell et al., 2020).

 Something else to keep in mind is that blood glucose maintenance during exercise may be challenging, but post-exercise may even be more difficult and unpredictable. Some diabetic athletes elevate their blood glucose but have got to deal with hyperglycemia after training. A bolus insulin correction may be given. (Aronson et al., 2019) But for prolonged exercise, basal-insulin reduction or bedtime snacks are recommended to reduce the chances of hypoglycemia while sleeping. During exercise, carbohydrate requirements differ based on basal glucose, exercise timing, insulin administration, and other medications.

Obesity

Obesity is when the Body Mass Index (BMI) of a person is ≥30 kg/m2. It has become more prevalent for the past two decades and is an epidemic. (Kjaer et al., 2015) Generally, type 1 diabetics are leaner as compared to type 2 diabetics. However, recent studies show that type 1 diabetics can also become obese if nutrition is not regulated. The prevalence of type 1 diabetes has increased at a faster rate compared to the general population. (Conway et al., 2010) Excess body weight leads to uncontrolled metabolism and higher risks for cardiovascular diseases among others. The Diabetes Control and Complications Trial showed that patients who received a higher dosage of insulin gained more weight. Over five years, these patients who received multiple daily injections or continuous subcutaneous insulin infusion gained an average of 4.6 kilograms. (Mottalib et al., 2017) Part of the weight gain is associated with glucose correction. Weight gain with type 1 diabetics who are taking intensive insulin treatment is a complicated process to adjust as insulin is the primary medication for their disease.

The Importance of Family Support

It is not surprising how parents play a major role in the health of children, as they are usually the ones preparing meals and purchasing food for their children. However, there are parents who are busy with work and don’t have the time or means to cook, tending to opt for processed foods. (Mańkiewicz-Żurawska et al., 2019) Unfortunately, these foods contain high fat, calorie, sodium, and sugar content which are just stored in the body as excess. Home cooked meals according to the Mediterranean diet, which contain high dietary fiber, is preferred as they contain the necessary nutrients without preservatives. An 18-month randomized clinical trial of about 136 parent-youth dyad participants (between 8–16 years old) diagnosed with type 1 diabetes for over a year before the trial was conducted. It was found that family support can lead to improvement in diet quality, however further research must be done as the study was only done to a limited number of people and is not applicable for all. (Nansel et al., 2015). This was one of the primary studies emphasizing children’s family and its link to children’s health.

Summary

Vegetarian diets may be attractive because they eliminate undesired sodium, sugars, cholesterol, and fats. However, they also eliminate vital nutrients needed for proper growth and development. Type 1 diabetic patients may be vegetarian, but supplements must be taken to make up for the lack of other vitamins, protein, and nutrients. (Tromba et al., 2021) Vitamin B12, iron, zinc, and n-3 fatty acid levels should be closely monitored to avoid damage to the nervous system among other diseases. Unfortunately, alternatives to treat type 1 diabetic patients are limited. (March et al., 2021) Therefore, prevention and management of obesity continues to rely upon early, consistent, and individualized dietary counseling and follow-ups. It is important to consult with your endocrinologist, nutritionist, and clinician team prior to committing to any sport or intense physical activity. Adjustments in food, insulin, and exercise schedule should be personalized to each diabetic athlete.

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