Medical Nutrition Therapy

MEDICAL NUTRITION THERAPY Journal of Diabetes and
Jour of Diab and Endo Assoc of Nepal 2018; 2 (1): (36-43)

Endocrine Association of Nepal
ISSN Print 2594-3367 ISSN Online 2037-2107
REVIEW ARTICLE OPEN ACCESS

MEDICAL NUTRITION THERAPY
Bhattarai Jyoti
TUTH, Visiting Faculty, Department of Internal Medicine
Kathmandu, Nepal
INTRODUCTION their lives with happiness and joy and at the same
Diabetes can lead to devastating expensive time help prevent devastating complications of
complications such as eye blindness, heart disease, diabetes.
stroke, leg amputation etc. To prevent such
complications of diabetes it is really important that Types of nutrients obtained from human diet
health care workers including patients understand There are various kinds of essential elements that
the ways of improving or reducing the chances of we get from food. We totally depend on our food for
developing such complications. It has been proven energy source but if the energy source is too much
that proper management of diabetes early on can or too little it can negatively impact our health. The
reduce such expensive and painful complications1. macronutrients called fat, protein and carbohydrate
are the main sources of energy from human diet. We
Proper management comprises of lifestyle also get vitamins and minerals that are essential for
modifications that include proper exercise, balanced different reactions occurring in the body. Before
nutritious diet, taking pills on regular basis, getting understanding medical nutrition therapy and their
regular check-ups and keeping different parameters roles in diabetes we need to understand what type
of the health in recommended range. of nutrients we get from the food we eat.
Lifestyle modification is an integral part of diabetes We mainly get two types of nutrients from our food;
management. It comprises of regular exercise and macronutrients and micronutrients:
proper nutrition. Proper nutrition is very important
in diabetes care. When nutrition education is given Macronutrients
and applied on a day to day, basis, with the intention Macronutrients are the main backbone of our
of improving disease care and improving longevity nutrition and they provide the bulk of our energy.
and quality of life, it is called medical nutrition Macro nutrients are carbohydrate, protein and fat.
therapy. They are the main sources of energy from human
diet.
Nutrition
Nutrition is an assortment of different quantity and Micronutrients
quality of nourishing elements that are found in Micronutrients are nutrients that are necessary in
food. People eat food to obtain nourishing essential minute quantities. Still they are essential for our
elements for sustaining life, to satisfy their taste overall health. Examples are vitamins and minerals.
buds and also for social reasons. If people are not
empowered by appropriate knowledge they may Fiber and Water
end up eating wrong quality and quantity of food In addition to macronutrients and micronutrients
that may be negatively impacting their diabetic we get essential elements from our food such as
care. Medical nutrition therapy helps the patients fiber and water. Our body is made up of two third
get empowered and learn to make the right choices. water and water is essential for our existence.
When they chose the right quality and quantity
of food their sugar and cholesterol level can be
maintained in desired range. They can go on about
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Jour of Diab and Endo Assoc of Nepal 2018; 2 (1):(36-43)

Units of energy: Fat
Unit of energy is expressed in kilo calories or in Fat is an essential nutrient in our food. We get
kilo joules. Energy density of food or diet is fat from both animal and plant sources. But fat
metabolizable energy per unit per weight of food2. from plant source is considered better, except for
Fat is a high energy density food because one- few exceptions such as palm oil, coconut oil and
gram fat gives nine kilo calories whereas one gram hydrogenated vegetable oils. Fat is also called lipid
of protein or carbohydrate source gives four kilo and it is insoluble in water. Fat or lipid is essential
calories. There are other fruits and vegetable which for the integrity of cell wall and essential for
may be having low energy density. For example, transportation of vitamins such as A, D, E and K.
cucumber has a lot of water in it. Cucumber has The smallest unit of fats or lipids is called fatty acid.
minimal amount of carbohydrate and protein and There are various types of fatty acids obtained from
no fat at all. Thus it is a low density food. It is food i.e. saturated fatty acids, polyunsaturated fatty
important to understand the energy density of food acids and mono-un-saturated fatty acids. Saturated
so that we can incorporate this information in the fatty are those fatty acids which have all the available
medical nutrition therapy. bonds of carbon occupied. Mono unsaturated fatty
acids have a single point of unsaturation. Example
Carbohydrate of mono saturated fatty acid is oleic acid. Poly
Carbohydrate is the most common source of stable unsaturated fatty acids have many double bonds in
food in many parts of the world. Carbohydrate is carbon chain the example of which is ecosapenta
generally obtained from cereals and to a lesser ionic acids. Saturated fatty acids are considered to
degree from pulses and fruits. The basic unit of be more harmful than mono-un-saturated fatty acid
carbohydrate is a simple sugar. Examples of simple and poly unsaturated fatty acids.
sugars are fructose, galacatose and glucose. If one
simple sugar is combined with another simple sugar Trans fatty acids
it is called disaccharide such as sucrose and lactose. When unsaturated fatty acid is converted to
When there is a big polymer of multitude of simple saturated fatty acid with the help of reaction with
sugar it is called polysaccharides. There are two hydrogen the process is called hydrogenation.
types of polysaccharides i.e. starch and non-starch Fatty acids, which are hydrogenated, are called
polysaccharides. Nonstarch polysaccharides are Trans fatty acids. Trans fatty acids are harmful to
generally soluble plant carbohydrates and they the body.
are mostly considered fiber. They pass through the
gut without absorption and they are considered Animal fat have more saturated fatty acids. Plant
important to form the bulk of the stool and also based oils such as soya oil, mustard oil, olive and
cause slow absorption of other carbohydrates. sunflower oil have high amount of poly unsaturated
fatty acids. Fish oil is also a source of unsaturated
Protein fatty acid and they have ecosapenta ionic acid and
Protein is one important nutrient that we get from DHA. Those fatty acids which have unsaturated
our food. It is nitrogen containing component of bonds are considered to be healthy for human diet.
diet. It is made up of various amino acids. Protein As fat is high in energy, altering the quality and
is obtained from both animal and plant source. It is quantity of fat can improve your energy intake. Fat
broken down into amino acid by gut enzymes and is a high energy density of food, as it can give a
absorbed in the system. It is essential to synthesize large amount of energy , the recommendation is to
various compounds in the body. We need continuous eat low fat diet .
replacement of protein for wear and tear so our food
should have certain amount of protein in the diet. Definition of Medical nutrition therapy
Medical Nutrition Therapy is defined as nutritional,
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diagnostic, therapeutic and counseling services cholesterol,blood pressure and waist circumference
for the purpose of disease management which 3. Maintain pleasure of eating by providing positive
is provided by registered dietician or nutritional messages about food choices
professional or physician3. Medical nutritional 4.Delay or prevent the devastating complications of
therapy is a legal term that is mainly used in the diabetes.
United States. Nutritional therapy’ is the term 5. Provide individuals with practical tools for
that is used in various studies that have been done day to day meal planning rather than focusing in
outside of the US. Thus it will be more inclusive individual micro-nutrient or single food.
of the broad spectrum of recommendations that fall 6. Uplift the feeling of wellbeing and carry the daily
under dietary education and management offered activities.
to patients to manage diabetes. Nutrition therapy 7. Avoiding unhealthy intake of harmful substances
is very important for patients with diabetes and like smoking and alcohol
pre-diabetes. Dietary intervention in diabetes has
proven that the hemoglobin A 1C can be reduced Macro nutrient percentage:
with the help of nutrition therapy4. People have widely differing energy intake and
proportional energy contribution from carbohydrate,
Nutrition therapy provided by a registered dietician protein and fat sources.
has been found to be associated with decrease of
hemoglobin A1C of 0.3-1% of people with type 1 One study showed that in the US, people with type
diabetes (4) and 0.5%-2% for people with type 2 1 and type 2 diabetes report and obtaining about
diabetes5. 45% of total energy from carbohydrate, 35-40%
from fat and 16-18% energy intake from protein 9.
Important components of Medical Nutrition There is no ideal percentage of total energy derived
Therapy or Nutrition Therapy are6 from one particular type of macronutrient. There
1. Nutrition Assessment is no evidence to suggest clearly that, sticking to
2. Nutrition Diagnosis strict percentage of calories from carbohydrate,
3. Nutrition Interventions protein and fat for all person of diabetic is helpful8.
4. Nutrition Monitoring and Evaluation with Macronutrient distribution should be based on
ongoing follow up to support long term lifestyle individualized assessment of current eating
changes patterns, preferences and metabolic goals8.
5. Evaluation of Outcomes and Modify
interventions as needed. Energy Intake (Energy Balance)
Various studies have shown that intensive lifestyle
Providing Nutrition Therapy to individuals is modification in patients with impaired glucose
challenging in resource poor countries. Even in tolerance or diabetes can lead to weight loss, which
more developed countries it is an under unitized in turn leads to better sugar control and better lipid
tool of diabetes management. One study showed panel 10,11,12. Weight loss has been shown to
that only 9% people interviewed and one diet visit reduce hemoglobin A1C and blood sugar profile.
in the last one year 7. In the Look AHEAD trial, intensive lifestyle
intervention was associated with weight loss of 6%
The goals of nutrition therapy8 at the end of intervention. The study population
The goal of nutrition therapy is to: had to be seen 3-4 times monthly over a year and
1.To promote and support healthful eating pattern 1-2 times each month for the reminder of the trial.
2. Maintain healthy weight and various parameters The total trial was of the period of 9.6 years 13.
of diabetes care in the desired range such as fasting, Look AHEAD calorie goals were 1200-1500 Kcal/
pp (post prandial) blood sugar, hemoglobin A1C, day for weights less than 114kg group and 1500-
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1800kcal /day for more than 114kg group and they to be lower16. In places with poor socioeconomic
were provided with less than 30% fat 14. In resource condition, lower education level and understanding
poor developing countries, with lack of health this type of education may be difficult. Alternative
professionals and dietitians, this type of intensive simpler way of teaching them portion sizes has been
consultation will definitely be challenging and out found to be effective. It may be better especially
of reach for many people. for elderly individuals and those with cognitive
dysfunction.
Weight loss diet and outcome in Diabetes
Mellitus type 2 Example of simple ways of educating people about
diabetes nutrition amount and portion size may be
In type 2 patient who has obesity or central obesity, plate method or Zimbabwean hand jive model as
modest weight loss defined as weight loss of more proposed by Dr.K Mawji. In Zimbabwean hand jive
than 5% is needed to produce desired outcome in model, starches or carbohydrate containing food to
glycemic control. Weight loss can be obtained with be taken in one meal is the amount that can hold in
lifestyle program that leads to 500-750kg/calories 2 fists. The amount covering the palm of one hand
negative energy balance or provide about 1200 is for protein containing foods. And green non-
-1500 kcal/day for women and 1500-1800 kcal for starch vegetables, will be as much as can be held
men15. by 2 hands. Oil is to be taken less than equivalent to
tip of the thumb.
Carbohydrate
As carbohydrate containing food are the ones In plate method, non-starchy vegetables fill up the
contributing to the post meal blood sugar level, half of a 9 inches’ plate. Of the remaining half, one
it is very important to know which food contains quarter of the plate has to be filled by grains and
carbohydrate. starchy food, which are actually the main source of
carbohydrate. The remaining quarter is for protein
containing foods such as meat and dairy. One can
Carbohydrate counting and diabetes
add healthy fat such as vegetable oil, nuts in small
management
amount. Add a serving of fruit and a non caloric
For individuals who take secretagogues or insulin, to
drink such as water, tea or coffee.
reduced risk of hypoglycemia, it is recommended to
eat source of carbohydrate at every meal. Skipping
meal is not recommended. As physical activity can
Glycemic index
According to ADA review, the association of
lower the blood sugar abruptly, it is recommended
glycemic index and glycemic loads with diabetic
for them to carry carbohydrate with them all the
is complex (7). The concept of glycemic index
time to reduce the risk of hypoglycemia.
improving the diabetic management has not been
substantiated. A meta-analysis showed that some
For individuals with type-1 diabetes, it is
studies exhibit that intake of lower glycemic intake
recommended to count carbohydrate and match it at
carbohydrate can cause reduction of hemoglobin
the meal time insulin. Meals need to be consumed
A1C of -0.2% to -0.5%, though in these studies,
at similar times every day and insulin needs to be
there was no consistent definition of low glycemic
taken before the meal. It is recommended to eat
index food17.
similar amount of carbohydrate everyday to match
the set dose of insulin.
Dietary fiber and whole grain
When type 1 patients are taught about carbohydrate A systemic review of data did not show a significant
counting and matching the carbohydrate intake with improvement of glycemic control with high fiber
short acting insulin, their HbA1c has been found diet18. High dietary fiber showed a modest lowering
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of pre-prandial glucose and hemoglobin A1c of saturated and unsaturated fat21.
(-0.2to-0.3%) with more than 50gm fiber /day19.
ADA position statement on nutrition suggests that The supplementation of omega-3 fatty acid is not
based on existing research, acquiring fiber intake of recommended whereas obtaining polyunsaturated
50gm/day is unrealistic. Dietary fiber is associated fatty acids and monounsaturated fatty acids instead
with lower all cause mortality, thus people with of saturated fatty acids and trans-fatty acids from
diabetes are advised to consume at least the amount food sources is recommended8. Systemic review
of fiber and whole grains recommended for general about dietary supplement with omega 3 fatty acids
public, i.e. 14 gm fiber per 1000kal per day8. did not show improvement of glycemic control in
type 2 diabetic17.
Fructose
Fructose is obtained from fruit is called free Various dietary approaches in diabetes
fructose’. Free fructose is naturally occurring and People in different countries and various socio-
obtained from fruits. As long as its intake is not cultural situations have different food combinations
excessive, it is not detrimental. But fructose present and eating patterns. When people eat combinations
in corn syrup that are added in factory made food of food, they will be getting different combinations
such as sugary drinks have, should not be consumed of micro and macro nutrients. Various studies
to avoid excessive calories intake. High fructose have been done with the hope of finding best diet
syrup containing diet has been associated with combination for patients with diabetes.
dyslipidemia 20.
Different types of diet combinations studied
Protein intake in Diabetes
Research has not shown clearly the ideal amount of Mediterranean diet includes plant foods, minimally
protein intake for optimized glycemic control 15. processed, locally grown food, fresh fruits, limited
Protein improves satiety and should be part of the concentrated sugar, olive oil as main source of
diet. However intake goal should be individualized. dietary lipid. It has low to moderate amount of
15-20% of total energy intake from protein is dairy products such as cheese and yogurt, less than
recommended to patients with diabetes as it is to four eggs per week, red meat in low frequency
general population 15. and amount. According to one meta-analysis,
Mediterranean diet compared to other diet improved
People who already have diabetic kidney disease are glycemic control by reducing hemoglobin A1c of
not recommended complete restriction of protein. about -0.47%21.
Protein intake should be maintained at 0.8 gram/
kg per body weight per day. Protein restriction Low fat diet consists of vegetables, fruit and
below 0.8gram/kg per body weight per day is not starches. Protein and low fat dairy products22. Total
recommended15. fat intake is less than 30% of total energy intake
and saturated fat intake is less than 10%.23. Low fat
Protein enhances insulin secretion in type 2 diabetes diet can be beneficial when overall energy intake is
patients, high protein containing carbohydrate source reduced and the weight loss happens.
food should not be used to treat hypoglycemia 15.
Low carbohydrate diet has high protein intake such
Fat intake and Diabetes as meat, fish, chicken, egg, cheese, nuts and seeds,
Diabetes organizations in various countries fats from oil, butter, olive and vegetables low in
recommend optimal diet for patients with diabetes carbohydrate such as greens. Sugar containing food
that has less than 30% of energy intake from fat and grain products such as pasta, rice and bread
with moderate polyunsaturated fat and restriction are avoided. In research studies, the definition of
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very low carbohydrate diet is the one that has 21- Sodium
70 gram per day of carbohydrate and moderately The recommended daily intake of sodium
low carbohydrate one that has 30-40% of calories consumption is less than 2300 milligram per day.
contribution from carbohydrate 24. Low sodium intake less than 1500 milligram
A meta-analysis of low carbohydrate diet compared per day is not recommended as it may affect the
with other diet showed a decrease in hemoglobin palatability and it is challenging to achieve that in a
A1c of about -0.12%21. nutritionally adequate diet 15.
High protein diet has 30% energy intake from Conclusion

protein, 40% from carbohydrate, 30% from fat with Individualized meal planning to obtain proper
20 gm protein after 2 months. A high protein, low percentage of macronutrients is important in
carbohydrate, diet showed about -0.28%25. nutrition therapy. The food pattern or eating pattern
should be chosen according to the patient’s taste and
Mediterranean diet has been shown to improve cultural habits and palatability. It should be tailored
cardiovascular risk factors such as lipid pattern, to the patients’ need with focus on proper energy
blood pressure in patients with diabetes. Vegetarian balance and also matching with the medication
and low fat vegetarian diet did not consistently therapy that the patient is taking. Patients should be
improve glycemic control or cardiovascular disease. encouraged to take their meals in scheduled time.
There is no ideal eating pattern that can benefit They are advised not to skip meals as it can lead
all diabetes patients. There is no one size fits for to hypoglycemia especially while taking insulin or
all. Thus medical nutrition therapy has to be insulin secreting medication.
individualized.
Comprehensive nutrition therapy should be an
In DASH (The Dietary Approaches to Stop integral part of management of diabetes in all
Hypertension) diet you eat fruits, vegetables and low the patients. Due to lack of resources and lack of
fat dairy products and reduced in sodium level. 26. awareness amongst patients, doctors, policy makers
and society as a whole, providing such therapy to
Micronutrients all the patients with diabetes may be challenging. It
Micronutrients are essential for us. They are best is recommended that the policy makers realize the
obtained from natural sources rather than from importance of nutrition therapy and put resources
supplements. Supplementation with anti oxidants, in training and developing registered dieticians, so
vitamin C, etc is non advised due to lack of evidence that as a part of lifestyle modification therapy, it can
of efficacy. Supplementation of micronutrients such be offered to the patient. This approach can in turn
as chromium, magnesium and vitamin D, show reduce the burden of diabetes related complications.
conflicting and confounding results and thus they
are not recommended15. Reference for Nutrition Therapy
1. UKPDS Prospective Diabetes Study (UKPDS)
Rather than taking processed food, we recommend Group. Intensive blood-glucose control with
high fiber nutrient dense carbohydrate containing sulphonylureas or insulin compared with
food, which provide vitamin and minerals and fiber conventional treatment and risk of complications
and lower calories. in patients with type 2 diabetes. Lancet. 1998;
352;837-853
Consumption of sugar sweetened beverages, 2. Webb PG . Nutrition maintain and improving
processed foods that are marketed as low fat or non health 2012
fat food product but that have a high amount of fine 3. US department of Health and Human Services:
grain added sugar should be strongly discouraged15. Final MNT regulations. CMS- H69FC Federal
- 41 -

Register 1 November 2001, 42 CFR parts 405, 410, of the lifestyle intervention and the evidence
411, 414 and 415 supporting it. Obesity 2006; 14(5);737-752
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plasma glucose to diet therapy in newly presenting trial BMJ 2002;325:746-9
type II diabetic patients Metabolism 39; 905-912, 17. Wheeler ML , Dunbar SA, Jaacks LM et al.
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1124
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MEDICAL NUTRITION THERAPY Journal of Diabetes and

Jour of Diab and Endo Assoc of Nepal 2018; 2 (1): (36-43)

REVIEW ARTICLE OPEN ACCESS

REVIEW ARTICLE OPEN ACCESS

REVIEW ARTICLE OPEN ACCESS

REVIEW ARTICLE OPEN ACCESS

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High protein diet has 30% energy intake from Conclusion

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