Diabetes _I

been whether the sugar lost in the urine of persons with diabetes should be
replaced or whether carbohydrate intake should be restricted to prevent
further sugar loss. The fluctuations in recommendations for the relative
proportions of carbohydrate and fat in the diet of persons with diabetes are
outlined in Table 5-l.

In Egypt, the Ebers papyrus of 1550 B.C. described the use of wheat grains,
fresh grits, grapes, honey, berries, and sweet beer "to drive away the
passing of too much urine" (Wood and Bierman 1972). Around the time of
Christ, Aretaeus, a Cappadocian from a Roman province in East Asia
Minor, recommended a diet of milk, cereals and starch, fruits. and sweet
wines-another high-carbohydrate diet. Willis, in the 17th century, was the
first to describe in English medical literature the sweet taste of diabetic
urine. He believed that the lost sugar should be replaced and recommended
a diet rich in carbohydrates but limited to milk and barley water boiled with
bread.

Later, Rollo, a surgeon general of the Royal Artillery in the English Army,
deviated from the common diet of the time and recommended complete
avoidance of dietary carbohydrates. He advocated "animal food and con-

Table 5-l

  History of Dietary Composition (Relative Proportion of
Carbohydrate and Fat Calories) Used in Management of Diibetes

Date            Source

Carbohydrate

Fat

1550 B.C. (approx.)  Ebers papyrus @gwt)  High
1 A.D. (approx.)    Aretaeus (Asia Minor)   High
1675            Willis          High
1797            Rollo           Very low      High
1860-80          Bouchardat          Low        High
1900-20        Naunyn; Allen      Low (+ fasting)   Low
1900-20          von Noorden       High
1923          Geyelin
1929          Sansum     Efmal       Normal
1931            Rabinowitch         Moderate       LOW
1935           Himsworth       High
194040        Kempner; Ernest     High          Low
1940-70        ADAa (U.S.)        Limited        Moderate
1971 to date      ADA (U.S.)        increased       Reduced

V4DA = American Diabetes Association.

Source: Bierman, E.L 1979. Nutritional management of adult and juvenile diabetics. In
   Nutritional manegement of genetic diso&m, ed. M. Winick, pp. 107-17. New
   York: Wiley. Copyright 1979, John Wiley & Sons, Inc.. reprinted with permission.

251


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finement, with an entire abstinence from every kind of vegetable mat-
ter. . . ." (Wood and Bierman 1972). The noon meal prescribed by Rollo
consisted of "plain blood puddings, made of blood and suet, and dinners of
game or old meats which have been long kept, and as far as the stomach
may bear, fat and rancid old meats, as pork." Pile of the University of
Pennsylvania believed in Rollo's approach but found that while it met with
some success, ". . . unfortunately for the patient he soon becomes so
disgusted with this kind of diet as to refuse it altogether, and returns to his
old manner of living, which in no little while neutralizes all the efforts of
months of abstinence." In France, Bouchardat introduced green vegeta-
bles into the Rollo diet to decrease the monotony. Bouchardat, often
referred to as the most brilliant clinician in the history of diabetes, noted
that the urinary sugar levels of his patients with diabetes fell during the
German blockade of Paris in the France-Prussian war of 1870 to 1871, a
time of food shortages, and he developed the concept of caloric deprivation
for diabetes treatment (Wood and Bierman 1972).

Shortly before the discovery of insulin, the dietary treatment of diabetes
was based on the teaching of Naunyn, a German physician who believed in
limiting both protein and carbohydrates and, in the most severe cases, total
caloric intake. Allen of the Rockefeller Institute modified Naunyn's recom-
mendations, and in 1912 with the "Allen Starvation Treatment," he showed
that weight loss due to caloric restriction was beneficial to overweight
persons with diabetes. Although low-carbohydrate and low-calorie diets
predominated from the time of Roll0 to the advent of insulin, the carbohy-
drate "cures" also had followers. For example, von Noorden of Frankfurt
and Vienna found that patients showed marked improvement when placed
on oatmeal diets for the treatment of digestive disturbances.

The discovery of insulin in 1921 led to a reappraisal of the diabetic diet.
Geyelin of Columbia University was the first to try high-carbohydrate diets
in patients treated with insulin beginning in 1923. He expected an increase
in the need for insulin with the high-carbohydrate diets but found some
cases in which insulin requirements were actually lowered. In 1929, San-
sum, Gray, and Bowden recommended in their textbook that persons with
and without diabetes should have the same diet because it would be more
palatable; thus, people would follow it more consistently, and improved
physical and mental activity would result. At about the same time,
Rabinowitch of McGill University recommended that patients stay 5 to 10
lb under their average body weight and advocated the use of low-fat diets
(less than 50 g/day) for this purpose, noting that "if we could lower the
incidence of cardiovascular-renal disease . . . our diabetic death rate would
correspond to that of normal populations" (Wood and Bierman 1972). In

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1935, Himsworth of the University of London observed that the glucose
tolerance of normal subjects improved consistently as the percentage of
carbohydrate in the diet increased. Other workers, such as Kempner of
Duke University (using a rice diet providing 90 to 95 percent carbohydrate)
and Ernest and coworkers at the University of Goteborg (using a 72 percent
carbohydrate diet), noted improvements in both serum cholesterol levels
and diabetic symptoms. Despite the preponderance of this evidence, low-
carbohydrate, high-fat diets continued to be widely used.

Since the early 1970's, this trend has been reversed, based on new studies
demonstrating that high-carbohydrate intakes lead to improvement in
glucose tolerance and insulin sensitivity (Bierman et al. 1971; Brunzell et
al. 1971; Brunzell et al. 1974). The change to a higher carbohydrate diet was
intended to reduce total and saturated fat to levels associated with de-
creased risk of atherosclerotic heart disease (Bierman and Ross 1977). In
the present era, the availability of insulin has allowed clinicians to move
beyond short-term prevention of hyperglycemia and other metabolic abnor-
malities toward the prevention, delay, or reduction of long-term complica-
tions. Nevertheless, the question of how much carbohydrate should be in
the diabetic diet remains controversial (Reavan 1980; Jarrett 1981).

Throughout history, few physicians or researchers have agreed about the
best approach to nutritional therapy of diabetes. No specific dietary ap-
proach beyond caloric restriction and weight loss in the obese has proved
more advantageous than another. Even recent trends toward the use of
high-carbohydrate, low-fat, high-fiber diets (described later in this chapter)
need further validation. Clinicians must still make therapeutic decisions
about diet based on inadequate information, yet they are increasingly able
to attain treatment goals through individualized diets, self-monitoring of
blood glucose, and more physiologic provision of pharmacotherapy. Fu-
ture research may better define the optimal "diabetic diet" and quantify its
contributions to therapeutic goals.

Significance for Public Health

The substantial impact of diabetes on the health of Americans has been
documented extensively (NDDG 1985). Approximately 11 million people
in the United States are estimated to have diabetes, but almost halfare not
yet diagnosed (Harris et al. 1987; Kovar, Harris, and Hadden 1987). In
addition to Type I and Type II diabetes, gestational diabetes (impaired
glucose tolerance during pregnancy) occurs in 2 to 5 percent of all pregnan-
cies, placing both mother and baby at special risk, but in 98 percent of these
cases the condition is transient and the mother returns to normal after the
baby is born (NDDG 1985).

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O Nutrition and Health

Diabetes is directly responsible for nearly 36,000 deaths each year in the
United States, making it the seventh leading cause of death. It also contrib-
utes to nearly 95,000 additional deaths per year, 75 percent of which are
due to cardiovascular complications (Kovar, Harris, and Hadden 1987).
Mortality rates for white males and white females with Type I diabetes are
5 to 11 times greater, respectively, than for the general population. Type II
diabetes prevalence is 33 percent higher for blacks than for whites, and
mortality rates for blacks with this condition are twice those for whites.
American Indians and Alaskan Natives have mortality rates from Type II
diabetes 2.3 times that of the general population, with the highest world-
wide rate of diabetes occurring among the Pima Indians in the United
States (DHHS 1985).

Mortality rates increase with age. Twelve percent of patients with Type I
diabetes die within 20 years of onset, primarily from acute complications
below age 20 and from renal complications above this age. Type I diabetes
is especially serious at younger ages; half the diagnosed cases are in
children under age 20, and the condition is second only to cancer as a
chronic illness in this group. The survival of persons with Type II diabetes
is only 70 to 80 percent of that expected for the general population 25 years
after diagnosis (NDDG 1985).

Many of the adverse health effects of diabetes derive from its complica-
tions (see Table 5-2). Diabetic ketoacidosis is responsible for 2 to 14
percent of hospitalization for diabetes and is the underlying cause of 10
percent of diabetes deaths. Diabetes is the leading cause of new cases of
blindness among persons ages 20 to 74 and is responsible for one-fourth of
all new cases of end-stage renal disease and 40 to 45 percent of all non-
traumatic amputations in the United States. The risk of developing heart
disease is about twice as high among persons with diabetes as in the general
population, and ischemic heart disease is a factor in 50 to 60 percent of the
recorded deaths of adults with diabetes. Lipid abnormalities occur in a
substantial proportion of people with diabetes. Hypertension rates are also
twice as high among people with diabetes, and the risk of stroke increases
twofold to sixfold. Infants born to mothers with diabetes are at greater risk
for congenital anomalies, macrosomia, respiratory distress, jaundice, and
perinatal mortality (NDDG 1985). In addition, one-half of individuals with
diabetes suffer serious limitations of activity and one-third are unable to
work regularly. The economic cost of diabetes was estimated in 1985 to be
$13.8 billion per year, or about 3.6 percent of total health care costs in the
United States (NDDG 1985).

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Table 5-2

Clinical Complications of Diabetes

Deaths

o Each year, diabetes is the cause of about 36,000 deaths among Americans
and is a contributing cause in another 95.000 deaths.
Heart Disease and Stroke

o People with diabetes are two to four times more likely to have heart disease
and two to six times more likely to have a stroke than people who do not
have diabetes.

Kidney Disease

o Ten percent of all people with diabetes develop end-stage kidney disease
(where a person requires dialysis or a kidney transplant to live).
* Nearly 25 percent of all new patients with end-stage renal disease have di-
abetes.

Blindness

o Each year, 5,000 people lose their sight because of diabetes. Diabetic eye
disease is the number one cause of new blindness in people between the ages
of 20 and 74.

Amputations

o Diabetes causes about 45 percent of all nontraumatic leg and foot amputa-
tions in the United States.

Sources: American Diabetes Association 1996; Kovar 1987.

Key Scientific Issues

o Role of Obesity in Type II Diabetes
o Role of Specific Dietary Factors in Diabetes
0 Role of Dietary Therapy in Diabetes Management

Role of Obesii in Type II Diabetes

Obesity (see chapter on obesity) is strongly associated with the onset and
severity of Type II diabetes (O'Sullivan 1982). At least 80 percent of
persons with the Type II disease are more than 15 percent in excess of their
desirable body weight at the time of diagnosis. Some estimates suggest that
new cases of this condition could be reduced by nearly half by preventing
obesity in middle-aged adults (Wood and Bierman 1986). Much of the
increased risk of diabetes among black Americans and Pima Indians has
been attributed to high rates of obesity and its complications in these

255


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populations (DHHS 1985). The risk of diabetes increases with the degree of
obesity and its duration (NIH 1986) as well as by the specific distribution of
body fat; fat on the upper body is more associated with development of
Iype II diabetes than is lower body fat (Kissebah et al. 1982).

Type II diabetes is characterized by insulin resistance, which means that a
given amount of insulin does not work as efficiently as it does in non-
diabetic individuals. Obesity itself also can contribute to insulin resistance,
and insulin resistance can be profound when obesity is combined with Type
II diabetes. When this happens, the liver, skeletal muscle, adipose tissue,
and other target organs for insulin action do not respond appropriately,
perhaps because the number of insulin receptors has been reduced. As a
result, the pancreatic beta-cells secrete greater amounts of insulin. Thus,
an obese person with Type II diabetes may secrete normal to above-normal
amounts of insulin, but the hormone is relatively ineffective and blood
sugar levels remain high.

The specific cellular cause of the high blood glucose and other metabolic
abnormalities of Type II diabetes is still uncertain, although three defects
may be partially involved: a diminished pancreatic beta-cell response to
glucose, reduced synthesis or function of cellular receptors for insulin, and
an as yet uncharacterized defect in utilization of glucose following binding
to cellular receptors (Arky 1983).

Although the relationship of obesity to these defects remains to be estab-
lished, weight loss reduces insulin resistance as well as fasting and
postprandial blood glucose levels in overweight persons with diabetes
(Henry, Scheafer, and Olefsky 1985; Henry, Wallace, and Olefsky 1986;
Henry et al. 1986). Furthermore, significant caloric restriction lowers blood
glucose levels in these individuals even before weight loss occurs. Once
desirable weight is achieved, control of blood sugar levels can be accom-
plished by consuming just enough energy to maintain it. In general, the
more recent the onset of diabetes, the more responsive a person will be to
the beneficial effects of weight reduction. As weight falls to desirable
levels, improvements in cardiovascular disease risk factors-hypertension
and high blood lipid levels-also occur (Arky 1983).

While very low-calorie diets (fewer than 800 kcal) are usually reserved for
individuals with moderate to severe obesity (Stunkard 1982) diabetes and
other risk factors may demand that such measures be used under a doctor's
supervision. Although weight loss prescriptions are often difficult to imple-
ment (Wood and Bierman 1972), behavior modification to reduce calorie

256


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intake and promote exercise can be effective and improves prospects for
persons with diabetes (Arky 1983; NIH 1986).

Role of Specific Dietary Factors in Diabetes

Carbohydrates

A diet containing 50 to 60 percent of total calories as carbohydrate is now
recommended for individuals with diabetes (ADA Task Force 1987), not
only because high-carbohydrate diets improve glucose tolerance and in-
sulin sensitivity (Bnmzel et al. 1971; Brunzel et al. 1974; Thompson,
Hayford, and Danney 1978), but also because the reduced fat-especially
saturated fat-intake that accompanies a high-carbohydrate diet lowers
cardiovascular risk. Still, some disagreement remains about the optimal
percentage of carbohydrate for persons with diabetes (Reaven 1980; Jarrett
1981). Furthermore, not all of the carbohydrate in a diet need be available
nutritionally; some of it can be in the form of fiber.

A more controversial issue is the relative proportion of simple and complex
carbohydrates that people with diabetes should consume. Blood glucose
and insulin levels sometimes respond differently to different types of
simple and complex carbohydrates in the diet (Crap0 1984). This response
can be expressed as a "glycemic index," which is the rise in blood glucose
following ingestion of a food as a percentage of the rise that follows
ingestion of a standard food. Food form, fiber type, digestibility of the
starch, and cooking and preparation procedures have been shown to affect
glycemic responses to foods. Even these responses may be altered when
foods are combined. Some studies have suggested that glycemic responses
to food combinations can be predicted from the glycemic index of the
carbohydrate components (Collier et al. 1986; Wolever et al. 198% where-
as others have failed to demonstrate predicted differences (Coulston and
Hollenbeck 1986; Laine, Thomas, and Bantle 1986). Although several
studies have suggested that positive clinical effects are produced when
persons consume diets containing low-glycemic-index foods (Kiehm, An-
derson, and Ward 1976; Simpson et al. 1981; Rivellese et al. 1980), these
suggestions are too preliminary to be considered a basis for therapy.
Because present knowledge of food composition and physiology does not
permit consistent prediction of glycemic responses, the use of glycemic
index tables is not currently recommended for people with diabetes (NIH
1986).

Some studies have been interpreted as supporting the idea that consuming
modest amounts of sucrose is acceptable in the diet of persons with

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Ll Nutrition and Health

diabetes as long as they can maintain adequate metabolic control (ADA
1984; ADA Task Force 1987). For example, some investigators have found
no significant differences in blood sugar levels among persons with di-
abetes consuming sucrose or starch (Bantle, Laine, and Thomas 1986), and
others have reported that consumption of fructose-a constituent of
sucrose-leads to only a minimal rise in blood glucose levels (Arvidsson-
Lenner 1976; Bohannon, Karam, and Forsham 1978; Lamar 1959; Crapo,
Kolterman, and Olefsky 1980; Crapo, Kolterman, and Henry 1986). This
last observation has led to the idea that a level of up to 75 g/day of fructose in
the diabetic diet may be acceptable if it does not compromise nutritional
adequacy (Olefsky and Crap0 1980). In other studies, however, high-carbo-
hydrate diets, sucrose, and fructose have all been reported to increase
blood glucose, insulin, and lipid levels in persons with diabetes (Coulston
et al. 1987; Hallfrisch et al. 1983). These inconsistencies have yet to be
resolved. Thus, a recent consensus conference recommended that sucrose
intake be permitted only in persons who are not overweight and who do not
respond to sucrose intake by increasing blood lipid levels, and that in any
case, sucrose not exceed 5 percent of calorie intake from carbohydrate
(NIH 1986).

Fat

The traditional restriction of carbohydrate intake in persons with diabetes
leads to an increased fat intake (and, usually, saturated fat) because the
percent of protein in human diets typically does not vary much. This high
saturated fat consumption may have contributed to the frequent cardiovas-
cular complications seen in past years among persons with diabetes. Per-
sons with diabetes have higher plasma cholesterol and triglyceride levels
and lower levels of high density lipoproteins than nondiabetic control
populations. To help reduce this increased risk for coronary heart disease,
a diet low in total fat, saturated fat, and cholesterol has been recommended
(ADA Task Force 1987). Although these recommendations are consistent
with those of the American Heart Association (see chapter on coronary
heart disease), their effectiveness in reducing the incidence and the sever-
ity of cardiovascular complications in diabetics has not been firmly estab-
lished. This can be explained in part because persons with diabetes (like
those with other kinds of disease) are usually excluded from participation in
the major diet-heart disease intervention trials. However, because these
dietary recommendations are consistent with those recommended for
other adults with high blood cholesterol levels and with good nutritional
practices, the person with diabetes should know about them.

Some individuals with diabetes do not maintain normal plasma lipid levels
despite a fat-restricted diet, perhaps because of accompanying obesity,

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uncontrolled hyperglycemia, or coexistence of a primary disorder of
lipoprotein metabolism. In such cases, the physician may need to prescribe
a more restrictive dietary regimen. If persons with diabetes exhibit poor
control of blood glucose levels accompanied by marked hypertriglyceride-
mia (plasma triglyceride levels over 1,000 mg/dl), they become at risk for
acute pancreatitis. This condition requires rapid treatment that may in-
clude restriction of dietary fat along with vigorous control of hyper-
glycemia through insulin or oral hypoglycemic agents.

Protein

The protein requirements of individuals with diabetes under good control
seem to be the same as those of healthy individuals: that is, a daily intake of
0.8 g/kg of body weight for adults and somewhat higher intakes for infants,
children, and pregnant or lactating women (NRC 1980). When insulin levels
are normal, protein is conserved in the body and the use of amino acids for
glucose synthesis is limited (Cahill 1970). In persons with poorly controlled
diabetes, dietary requirements may be increased because protein is used to
synthesize glucose.

Individuals with diabetes and concurrent renal insufficiency should avoid
excessive protein intake. Glomerular hyperfiltration (increased blood flow
and filtration across the renal glomerular capillary bed) leads to impaired
renal function in persons with diabetes, and increased protein intake may
exacerbate renal damage (see chapter on kidney diseases). Furthermore,
protein restriction slows the rate of decline in renal function in individuals
with diabetic nephropathy (Evanoff et al. 1987). Because past dietary
recommendations for persons with diabetes sometimes emphasized pro-
tein, and because the average American eats more protein than is necessary
to maintain health, current recommendations suggest that people with
diabetes should reduce protein intake below the level consumed by Ameri-
cans (ADA Task Force 1987).

Fiber

Recent studies have suggested that a higher intake of dietary fiber than is
typical for Americans might improve many clinical conditions, including
the abnormal glucose tolerance of diabetes (LSRO 1987). Some studies
have demonstrated that diets containing higher amounts of fiber (particu-
larly water-soluble fiber) and carbohydrate are associated with lower blood
glucose and serum lipid levels (Anderson 1980; Anderson and Chen 1979;
Wheeler 1982; Jenkins, Wolever, Jenkins, Lee, et al. 1983; Vahouny 1982).

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0 Nutrition and Health

Inconsistencies in the results of studies of fiber and diabetes may be due to
differences in types and properties of fiber. As discussed in the gastroin-
testinal diseases chapter, the water-insoluble fibers, such as cellulose,
lignin, and most hemicelluloses, affect gastrointestinal transit time and
fecal bulk but have a limited impact on plasma glucose, insulin, or choles-
terol levels (McMurray and Baumgardner 1984; Hall, Bolton, and Hetengi
1980). However, the water-soluble fibers-pectins, gums, storage polysac-
chat-ides, and a few hemicelluloses-have little influence on fecal bulk but
reduce serum levels of glucose and insulin (Wheeler 1982; Anderson 1980;
Anderson and Chen 1979; Vahouny 1982).

Studies also indicate that blood glucose levels immediately following a meal
are more influenced by soluble than by insoluble fibers. Further study of
the effects of insoluble fibers on long-term baseline blood glucose levels is
needed (Cohen et al. 1980; Jenkins, Wolever, Bacon, et al. 1980; Jenkins,
Wolever, Taylor, et al. 1980; Jenkins et al. 1977; Jenkins et al. 1976; Miranda
and Horwitz 1978; Monnier et al. 1981). Several reports since 1976 suggest
that purified fiber supplements help to control blood glucose in individuals
with diabetes and that they decrease fasting serum glucose, reduce
glycosuria, decrease serum cholesterol, and lower fasting serum triglycer-
ide levels (Anderson and Tietyen-Clark 1986). Such supplements are most
effective when they are mixed with food (Williams, James, and Evan 1980;
Cohen et al. 1980) and when the total carbohydrate level in the diet is high
(Jenkins, Wolever, Bacon, et al. 1980).

Very high-carbohydrate, high-fiber diets, providing 70 percent of calories
as carbohydrate and 35 g of plant fiber per 1,000 calories, consistently
improve glucose tolerance, decrease fasting plasma glucose levels, lower
insulin needs, and decrease serum cholesterol concentrations. These re-
sults have been confirmed in longer term studies comparing a more moder-
ate diet that provides 5.5 to 60 percent of calories as carbohydrates and 25 g
of plant fiber per 1,000 calories (Anderson and Tietyen-Clark 1986; Ander-
son et al. 1987).

These benefits may be related more to the increased intake of complex
carbohydrate than to fiber. Some studies suggest that the fiber content is
not the major factor that determines, for example, the serum glucose
response to consumption of cereals (Jenkins, Wolever, Taylor, Barker, and
Fielden 1981; Jenkins, Wolever, Jenkins, Lee, et al. 1983). Nevertheless,
increasing the level of fiber in the diet of a person with diabetes, or in the
diet of someone at risk for diabetes, may help lower blood cholesterol and
triglyceride concentrations (Anderson and Chen 1979; Albrink, Newman,
and Davidson 1979).


Diabetes 0

The optimal amount and type of fiber that improve diabetes symptoms are
not well defined. If, as evidence suggests, at least 15 g of fiber per meal
(depending on total daily calorie intake) are necessary to achieve therapeu-
tic benefits for persons with diabetes, major changes in dietary patterns are
required. And the use of some of the viscous, soluble fibers is generally not
practical because of their unpalatability and gastrointestinal side effects.
High-fiber diets also may impair absorption of essential trace elements and
be inappropriate in persons with autonomic neuropathy, a neurologic dis-
ease (NIH 1986).

Alcohol

Abstinence from alcohol is not necessarily required for adults with di-
abetes, but some potential problems need attention. Alcoholic beverages
add calories without nutritional benefit and may need to be restricted in
overweight persons. In addition, excessive alcohol consumption by a per-
son who is fasting or undernourished may lead to hypoglycemia, which can
be a serious problem in persons taking insulin or oral hypoglycemic agents.
Intoxication itself may impair a person's adherence to a prescribed man-
agement plan. Finally, alcohol ingestion may raise fasting and postprandial
plasma triglyceride levels. Considering the increased risk for cardiovascu-
lar disease in persons with diabetes, alcohol consumption should probably
be avoided if the person has concomitant hypertriglyceridemia. When
alcohol is part of the meal plan, the person's fat intake should be reduced
accordingly to account for the calories (7 kcal/g of alcohol) (see chapter on
alcohol).

Alternative Sweeteners

Nutritive alternative sweeteners are sugars such as fructose and sorbitol
that can be used as sources of calories. Aspartame, strictly speaking, is a
nutritive sweetener, but it is used in such small quantities that its caloric
contribution is minimal. Non-nutritive alternative sweeteners, such as
saccharin and cyclamate, provide virtually no calories in relation to their
sweetness.

Alternative sweeteners may be useful for persons with diabetes consuming
sugar-restricted diets, both to provide sweetness without associated hyper-
glycemia and, in some cases, to help reduce caloric intake in overweight
individuals (Porikos, Booth, and Van ltallie 1977). The risks, benefits, and
effects of the different sweeteners in individuals with diabetes have not
been evaluated fully, however, and there is little general agreement about
the desirability, acceptability, or usefulness of these substances in diabetes

261


treatment. It is not known, for example, whether alternative sweeteners
contribute to better diabetes control or whether they are effective in weight
reduction programs in Type II diabetes. Because persons with diabetes are
likely to ingest greater quantities of alternative sweeteners than the general
population, issues of side effects, safety, and risk are especially important.
The American Diabetes Association's current position on use of nutritive
and non-nutritive sweeteners is that they are acceptable in management of
diabetes (ADA Task Force 1987).

Role of Dietary Therapy in Diabetes Management

Management Goals

Lifelong care is required to avoid or to reduce the risk factors and com-
plications of Type I and Type II diabetes. Because strategies to control
hyperglycemia are similar to those used to reduce excessive blood lipid
levels, blood pressure, and body weight and their associated cardiovascu-
lar risks, dietary therapy is considered the key to diabetes management
(ADA Task Force 1987). Maintaining blood glucose as close to physiologic
levels as possible will prevent hypoglycemia and its consequent damage to
the brain and nervous system; it will also improve the outcome of pregnan-
cy for women with diabetes (ADA Task Force 1987). Whether control of
hyperglycemia will prevent or delay the development of long-term cardio-
vascular, renal, retinal, or neurologic complications, however, has not been
established (Wood and Bierman 1986).

In persons with Type I diabetes, the goals of dietary management are to
maintain appropriate body weight and prevent hypoglycemia (as well as
hyperglycemia). These are accomplished by consuming meals with an
appropriate calorie content at regular intervals, coordinated with the times
of insulin injection and levels of physical activity. Because individuals with
this form of the disease are usually young and lean, caloric intake must be
adequate to support normal growth and development.

In contrast, 80 to 90 percent of individuals with Type II diabetes are
overweight, and the first goal of diet therapy for such persons is weight
loss. Hence, for most of these individuals, restriction of caloric intake and
increased physical activity leading to moderate weight loss may be suffi-
cient to control blood glucose levels and to avoid the need for insulin or
hypoglycemic medication (ADA Task Force 1987). Once desirable weight
is achieved, people with Type II diabetes must continue to adhere to the
recommended diet to maintain the reduced weight while consuming
amounts of nutrients necessary to maintain normal blood glucose levels.

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For persons with either type of diabetes, dietary therapy is concerned with
(1) maintenance of proper nutrition, (2) the total number of calories in-
gested, (3) the distribution of caloric intake throughout the day, and (4) the
individual food sources that make up these calories. The American Di-
abetes Association has issued general dietary recommendations for per-
sons with diabetes, and these are summarized in Table 5-3. Issues related
to the American Diabetes Association guidelines-patient education strat-
egies, exchange lists, counseling-are discussed below. However, to en-
sure the most appropriate diet for any given person with diabetes, individu-
al diet plans should be developed with a trained dietitian or nutritionist
(Nuttal, Maryniuk, and Kaufman 1983).

Table 5-3

American Diabetes Association Dietary Recommendations
        for Persons With Diabetes

Dietary Factor

Calories

Carbohydrate

Protein

Fat

Cholesterol

Alternative sweeteners

Sodium

Recommendation

Should be prescribed to achieve and maintain a
desirable body weight.

Should comprise 55 to 60 percent of the calories with
the form and amount to be determined by individual
eating patterns and blood glucose and lipid responses.
Unrefined carbohydrates should be substituted for
retined carbohydrates to the extent possible. Modest
amounts of sugars may be acceptable as long as
metabolic control and desirable body weight are
maintained.

Should follow the Recommended Dietary Allowance
(NRC 1980) of 0.8 g/kg body weight for adults,
although more may be needed for older persons. Some
reduction in protein intake may prevent or delay the
onset of the kidney complications of diabetes.
Should comprise 30 percent or less of total calories,
and all components should be reduced
proportionately. Replacement of saturated with
polyunsaturated fat is desirable to reduce
cardiovascular risk.

Should be restricted to 300 mg/day or less to reduce
cardiovascular risk.

Both nutritive and non-nutritive sweeteners are
acceptable in diabetes management.
Should be restricted to 1,000 mg/l,O80 kcal, not to
exceed 3,000 mg/day, to minimize symptoms of
hypertension. Severe sodium restriction, however,

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Table 5-3 (continued)

Sodium (continued)   may be harmful for persons whose diabetes is poorly
           controlled and for those with postural hypotension
           (low blood pressure and consequent dizziness when
           first standing up) or fluid imbalance.
Alcohol         Should be moderate and may need to be restricted
           entirely by persons with diabetes and insulin-induced
           hypoglycemia, neuropathy, or poor control of blood
           sugar, blood lipids, or obesity.
Vitamins and minerals  Should meet recommended levels for good health.
           Supplements are unnecessary for persons with
           diabetes except when caloric intake is exceptionally
           low or the variety of food intake is limited. Calcium
           supplements may be necessary under special
               circumstances.

Source: American Diabetes Association Task Force on Nutrition and Exchange Lists.
   1987. Nutritional recommendations and principles for individuals with diabetes
   mellitus: 1986. Diabetes Cam 10:126-32. Reproduced with pen&ion from the
    American Diabetes Association, Inc.

Education Strategies

Better management of diabetes reduces hospitalizations and other person-
al and economic costs. To achieve these benefits, persons with diabetes
must practice optimal self-care, which, in turn, depends on both knowl-
edge and support. Education of persons with diabetes is associated with
improved self-care skills, dietary adherence, and control of blood glucose
and blood lipid levels (Mazzuca et al. 1986; ADA 1986) and results in cost
savings greater than the costs of the education program (Davidson, Del-
cher, and Englund 1979). Although coordinated outpatient education pro-
grams are the preferred setting for education of persons with diabetes, the
lack of third-party reimbursement for such programs has impeded their
development (ADA 1986).

Use of Exchange Lists. Exchange lists categorize foods into groups with
similar energy, protein, carbohydrate, and fat content and indicate how
they can be used in meals. Because individuals with diabetes plan meals
that contain specific proportions of protein, fat, carbohydrates, and calo-
ries, the foods within each group-starch/bread, meat and substitutes,
vegetables, fruits, milk, and fat-can be freely substituted (exchanged) for
one another in the amounts designated. The exchange system is widely
used in diet counseling and meal planning for persons with diabetes.
Exchanges are not intended to be used as self-instructional materials and
generally require a trained nutritionist to explain their use, to help tailor the

264


Diabetes 0

diet to the individual's needs, and to assess the individual's understanding
of appropriate food intake (Slowie 1977).

In 1976, and again in 1986, the exchange system was revised to reflect
current scientific knowledge. The 1976 version reflected recommendations
to restrict intake of calories, cholesterol, and saturated fat. It identified
meat exchanges with high, medium, and low saturated fat content; it
included the cholesterol content of meat and fat exchanges; and it provided
the relative content of polyunsaturated and saturated fats (ADA and Amer-
ican Dietetic Association 1976). The 1986 revision retained these features
but changed the order of the exchanges to emphasize high carbohydrate
and high fiber intake and to update information about the nutrient content
of breads and fruits. Symbols were added to identify foods with high
sodium and fiber content, and lists of combination foods and foods recom-
mended for occasional use were added (Franz et al. 1987).

Dietary Counseling. Dietary counseling helps the person with diabetes
achieve good control of blood glucose and lipid levels by consuming
appropriate levels of calories and nutrients, maintaining consistency in the
timing of meals and snacks, and developing meal plans appropriate to
individual lifestyle and food preferences. Additional goals are to help
children and adolescents achieve normal growth and development rates
and to encourage adequate nutrition for the pregnant woman.

Despite the evident importance of dietary therapy, individuals with di-
abetes often fail to adhere to the recommended diet. This problem means
that patients and physicians must understand the importance of dietary
management goals and methods; in addition, practitioners must provide
detailed nutrition counseling (Hauenstein, Schiller, and Hurley 1987).
Although physicians have sometimes perceived dietary noncompliance as
the patient's fault, persons with diabetes have reported that dietary ad-
herence depends more on environmental factors (e.g., family, job, eco-
nomic status) or on physiologic factors (e.g., visual or ambulatory restric-
tions) that interfere with food purchase or preparation than on personal
control. Understanding these different perceptions can help individuals
with diabetes to assume greater responsibility for their own care (House,
Pendleton, and Parker 1986).

Meal planning for persons with diabetes can be based on several alternative
approaches: (1) dietary guidelines, such as the USDA/DHHS Dietary
Guidelines for Americans, supplemented with information specific to di-
abetes; (2) exchange lists (discussed above); (3) counting systems to
monitor total caloric and glucose consumption; and (4) sample menus

265


0 Nutrition and Health

tailored to the special needs of individuals (Green 1987). Any of these
methods may be appropriate for any given individual, but development of
an individual meal plan requires patient education both in principles of
good nutrition and in effective implementation of these principles. For the
most part, clinicians perform the initial examination, obtain a medical
history (including, perhaps, something about diet), outline an overall nutri-
tional plan, and refer the person with diabetes to a trained dietitian or
nutritionist for further counseling (Nuttall, Maryniuk, and Kaufman 1983).
The dietitian or nutritionist then obtains a detailed diet history, develops an
appropriate meal plan, and helps the person follow it by means of followup
contacts. The most effective approaches consider individual dietary, so-
ciocultural, economic, and lifestyle characteristics and involve the person
with diabetes in devising the diet plan (Nuttall, Maryniuk, and Kaufman
1983). Because behavior changes usually occur gradually, dietary counsel-
ing is also more effective when it presents information in small increments
that can be readily applied (Franz et al. 1987).

Nutrition information should be presented in stages to persons with di-
abetes. In the first stage, counselors should teach basic food selection skills
and develop simplified, individualized meal plans. In subsequent stages,
the counselor can provide more detailed information that extends and
reinforces existing knowledge and that helps the person to change dietary
behavior. Such information needs to be reinforced by continuing education
that reviews dietary management, evaluates adherence to the recom-
mended diet, provides further motivation to improve dietary behavior, and
incorporates the results of new information into the dietary management
program (Franz et al. 1986).

Implications for Public Health Policy

Dietary Guidance

General Public

Obesity greatly increases the risk for developing Type II diabetes, and
obesity is in turn related to caloric imbalance: excessive intake of energy
and/or insufficient energy expenditure. Because dietary fat contains more
than twice the calories of either protein or carbohydrate, a reduction in fat
intake should lead to a more favorable caloric balance, especially when this
dietary change is accompanied by appropriate levels of physical activity.
Controlling obesity by reducing dietary fat intake should help reduce the
prevalence of Type II diabetes and is also consistent with dietary recom-


Diabetes 0

mendations for the prevention of coronary heart disease, hypertension,
and some types of cancer.

Special Populations

Overweight persons with Type II diabetes benefit substantially from weight
loss and may accrue benefits when fat, salt, alcohol, and simple sugars are
reduced in combination with an appropriate increase in foods containing
complex carbohydrates and soluble fiber. Even moderate weight loss,
accomplished by reducing caloric intake and increasing energy expendi-

ture, reduces blood glucose and insulin toward normal levels.

Current research suggests that diets relatively low in fat and cholesterol,
salt, and protein can' reduce the risk of the long-term cardiovascular,
hypertensive, and renal complications of diabetes, respectively. Persons
with diabetes and concurrent insulin-induced hypoglycemia, neuropathy,.
or poor metabolic control should avoid alcohol. Although research has not
unequivocally established that complex carbohydrates and fiber improve
blood glucose and insulin levels in individuals with diabetes, diets higher in
these substances are generally lower in fat, cholesterol, and calories, and
they are associated with lower blood lipid levels and, therefore, lower risk
for coronary heart disease. Such diets can help reduce high blood choles-
terol levels and the risk for coronary heart disease.

Until similar uncertainties about the metabolic effects of sugar in persons
with diabetes are resolved, prudence dictates caution in the amount of its
use. Research on dietary management of Type I diabetes emphasizes the
`importance of weight maintenance, avoidance of hypoglycemia, and meta-
bolic control by coordinating caloric intake and expenditure with the
schedule of insulin administration. Information, counseling, and followup
on the appropriate application of these dietary principles and guidance for
dietary management should be provided to persons with diabetes by
qualified health professionals.

Nutrition Programs and Services

Food Labels

The food industry should be encouraged to provide nutrition information
on the labels of most food products. The information on calories, fat
(especially saturated fat), and other nutrient content will help the public to
control caloric intake and wiU help persons with diabetes to make the
necessary dietary modifications their physicians recommend.

261


0 Nutrition and Health

Food Services
Evidence related to the role of dietary factors in diabetes currently holds no
special implications for policy changes in food service programs.

Special Populations

Persons with diabetes of either type should be provided with counseling
and assistance with dietary changes to control their disease. This should be
coordinated with other aspects of their health care needs such as insulin
administration and levels of physical activity.

Research and Surveillance

Research and surveillance issues of special priority related to the role of
diet in diabetes should include investigations into:
o The role of calorie intake and physical activity, and subsequent weight
control, in the prevention of Type II diabetes.
a The metabolic consequences of obesity.
o The metabolic mechanisms of intestinal and hepatic processing of
dietary carbohydrate, and the effects of other nutrients and of fiber on
carbohydrate metabolism.

o The influence of dietary carbohydrates on glycemic responses in per-
sons with diabetes, and the effects of Such responses on development
of the cardiovascular, renal, retinal, and neurologic complications of
this condition.

o The influence of specific dietary factors-fat, cholesterol, sugar, pro-
tein, fiber-on development of the cardiovascular, renal, retinal, and
neurologic complications of diabetes.
o The long-term risks and benefits of non-nutritive sweeteners as aids to
adherence to dietary regimens.
o The behavioral and environmental factors that influence adherence to
weight loss and dietary regimens in persons with diabetes.
o The specific educational techniques that will improve acceptance of
and adherence to therapeutic regimens.

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Diabetes O

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Chapter 6
Obesity

They are as sick that surfeit with too much
  as they that starve with nothing.
  William Shakespeare (1X54-1616)
    Merchant of Venice, I.ii.

Introduction

Obesity is a condition of excess body fat. Because degree of fatness is a
continuum, any definition of obesity must be arbitrary and related to a
standard of normality. The standard of normality most commonly agreed
upon is the weight, adjusted for height, associated with longest survival.
Although the exact cutoff points for normality and the exact contribution of
obesity to illness and premature death are still under investigation, obesity
undoubtedly contributes to premature mortality, particularly when associ-
ated with elevated blood cholesterol levels, high blood pressure, or di-
abetes. Although poor health is not an inevitable consequence of obesity,
excess body fat poses health risks to many Americans. Despite rapid
advances in the definition and epidemiology of obesity, of adipose cell
metabolism, and of the causes and consequences of obesity, disagreements
still prevail on almost every key issue. Because the causes of obesity are not
well understood, knowledge about how to prevent and treat it is also
limited. This chapter outlines the current knowledge of the diagnosis, risks,
causes, and treatment of obesity, calls attention to areas of controversy,
and assesses the implications of this knowledge for public health policy.

Historical Perspective

Historians of obesity, finding few scientific records, have searched for
clues in linguistics, history, and art and have concluded that obesity as it is
now known did not occur in England, except in a few isolated instances,
until it began to appear in the English upper classes in the 18th and 19th
centuries (Trowel1 1975).

275