I

n

u Nutrition and Health

There is some suggestive but not conclusive evidence that correlates
consumption of salt-pickJed, salt-cured, and smoked foods with stomach
and esophageal cancers, indicating that the public should continue to limit
its intake of these foods to the current low levels of consumption.

Special Populations

Persons at high risk for diet-related cancers because of family history,
obesity, or excessive alcohol intake should receive counseling from
qualified health professionals to design approaches that could reduce their
elevated risk for cancer.

Patients with cancer should receive appropriate nutritional support and
dietary advice to maintain optimal nutritional status throughout medical,
surgical, or radiological therapy. There is no credible evidence that nutri-
tional changes specifically help in the cure of cancer patients.

Children and older persons are not currently targeted by the dietary guide-
lines relative to cancer risk due to limited data for these groups.

Nutrition Programs and Services

Food Labels

Evidence related to the role of dietary factors in cancer suggests that food
manufacturers should include on package labels information about nutri-
tional content of the food, especially for fat and carbohydrate components
(and including fiber components to the extent permitted by analytical
methods).

Food Services

Evidence related to the possible role of dietary factors in cancer suggests
that the public might benefit from increased availability of foods low in fat
and high in fiber.

Food Products

Evidence related to the role of dietary factors in cancer suggests that foods
low or reduced in calories and fat and high in fiber should be made
increasingly available by food manufacturers.

Special Populations

Persons with cancer should be provided with counseling and assistance in
the development of diets appropriate to their condition.

226


Cancer 0

Research and Suweillance

Research and surveillance issues of special priority related to the role of
diet in cancer should include investigations into:
o Molecular mechanisms of carcinogenesis and the ways in which ini-
tiating or promoting events may be affected by specific components of
dietary fat, fiber, protein, alcohol, vitamin A, carotenoids, and other
  vitamins or minerals.

o Quantitative relationships between food and nutrient intake and can-
cer incidence through chemoprevention and dietary clinical trials.
o The effect of specific components of dietary fat, fiber, vitamin A, and
carotenoids on cancer etiology.

o Interactions between dietary factors such as fat, fiber, calories, pro-
tein, and specific vitamins and minerals in cancer prevention and
causation.

o Development of biochemical markers of dietary intake to better
monitor effects of dietary intervention on cancer risk.
o Patterns of food intake best associated with cancer prevention.
o Development of national population data on food and nutrient con-
sumption patterns and specific cancer rates, including more accurate
assessment of intake of specific dietary factors within relatively homo-
geneous population groups.
o Levels of carcinogenic and mutagenic substances in the food supply.
o Dietary guidance methods that are most effective in helping people
improve patterns of food intake.
o The causes of wasting and malnutrition in cancer patients and the
effects of nutritional support on response to therapy and survival in
these patients.

227


0 Nutrition and Health

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Chapter 5

Diabetes

. . . urine wonderfully sweet, as if imbued
     with honey or sugar.
  Thomas Willis, physician to
   Charles II of England, 1670

Introduction

Diabetes mellitus (commonly called diabetes) is the name given to a spec-
trum of conditions found in 11 million Americans. Diabetes is charac-
terized by metabolic abnormalities (of which the most evident is hyper-
glycemia, an elevated concentration of glucose in blood) and by long-term
complications involving multiple organs, especially the eyes, kidneys,
nerves, and blood vessels. These complications result from a deficiency of
the hormone insulin, a reduction in the effectiveness of insulin, or other
less well understood metabolic disorders. There are two major forms of
diabetes mellitus: Type I, or insulin-dependent, and Type II, or noninsulin-
dependent. These types are distinguished by the need in Type I diabetes for
exogenous replacement of insulin, which is necessary for the metabolism
of glucose. The treatment goal for both types of diabetes is to prevent or
reduce the risk and severity of complications; generally this goal is best
achieved by maintaining normal or near-normal blood glucose and blood
lipid levels. In longstanding diabetes, certain other aims of treatment
assume great importance, including blood pressure control and reducing
protein load on the kidney (see the following section and the chapter on
kidney diseases).

Type I diabetes, or insulin-dependent diabetes mellitus (IDDM), formerly
known as juvenile-onset diabetes, accounts for about 10 percent of di-
abetes in the United States. It is characterized by an absolute deficiency of
insulin, caused by beta-cell destruction of the islets of Langerhans in the
pancreas. Genetic factors, including an autoimmune response (Eisenbarth
1986), affect the risk of beta-cell destruction as well as environmental
factors such as viral agents or cytotoxic chemicals (Arky 1983).

249

-


u Nutrition and Health

Type I diabetes usually appears before age 40 and begins abruptly. Typical
symptoms are thirst, excessive urination, increased appetite, rapid weight
loss, breath that smells of acetone, and urine that is sweet because of its
high sugar concentration. Affected persons are usually of normal body
weight. Because their insulin levels are low, persons with Type I diabetes
require insulin for survival. Treatment usually includes administration of
insulin, diet coordinated with the insulin dosage schedule, and regular
physical exercise. At present, no method to prevent development of this
form of the disease has been identified (Browner 1986).

Type II diabetes, or noninsulin-dependent diabetes mellitus (NIDDM),
also known as adult- or maturity-onset diabetes, accounts for approximate-
ly 90 percent of all cases and affects at least 10 million Americans. It usually
appears in mid-life, most commonly among people who are overweight or
obese. Its onset is gradual, and many persons have a long history of mild
symptoms or display no symptoms at all. Often, the condition is first
diagnosed among individuals with no overt symptoms who display ele-
vated fasting blood glucose levels during a routine physical examination.
Genetic predisposition appears to play an important role in Type II as well
as in Type I diabetes.

Persons with Type II diabetes may display normal pancreatic histology,
secrete insulin in response to glucose ingestion, and have normal levels of
insulin in their blood. But because the body is less able to use this insulin,
or perhaps for some other as yet unknown reason (Feldberg, Pyke, and
Stubbs 1983, blood sugar levels are inappropriately high, and insulin levels
are insufficient. The three principal approaches to diabetes management
are diet, exercise, and treatment with oral antidiabetic agents or insulin.
Overweight persons able to lose weight can be managed by diet and
exercise alone. Some individuals unable to lose weight may respond to
treatment with sulfonylurea and other antidiabetic, hypoglycemic drugs
(agents that reduce blood sugar levels), but others will need insulin treat-
ment to control their diabetes.

Although it is generally believed that maintenance of normal blood glucose
levels will prevent or reduce the complications and premature mortality
associated with diabetes, this supposition has yet to be proved.

Historical Perspective

Since ancient times, diet has been recognized as a cornerstone of diabetes
management, yet ideas about the most effective dietary treatment have
varied widely throughout history (Bierman 1979). The uncertainty has

250