TO

Dr. Shaikh Shahinur Rahman

Associate Professor
Dept. of Applied Nutrition & Food Tech.
Islamic University, Kushtia.
Bangladesh.
 Diabetes Mellitus
• Diabetes mellitus is a metabolic disorder
characterized by persistent hyperglycemia
(raised blood glucose) resulting from defects in
insulin secretion or insulin action (resistance)
or both due to genetic and/or environmental
factors acting alone or together.
• The chronic hyperglycemia if not properly
treated is associated with failure of various
organs especially the eyes, kidney, nerve,
heart and blood vessels.

[Ref.: Mannual for Diabetes educators; Bangladesh Diabetic Somiti (BADAS) & World Diabetes Foundation (WDF); 2009]
 Development of diabetes mellitus
Food intake

Protein Carbohydrate Fat

Glucose

Lack of insulin or
insufficiency
Body cell

Increased glucose in blood

Diabetes

[Development of diabetes mellitus]

How insulin works?

How insulin works.MPV

 Standard of blood glucose value
Inference Fasting blood sample 2 hrs after meal
(mmol/L) (mmol/L)

Normal < 6.1 <7.8

IFG (Impaired Fasting Glucose) ≥ 6.1 to <7.0 <7.8

IGT (Impaired Glucose Tolerence) ≥ 6.1 to <7.0 ≥ 7.8 to < 11.1

DM (Diabetes Mellitus) ≥ 7.0 ≥ 11.1

•WHO Expert Committee 1999

Note: [ADA recommended in recent years that the normal level

of fasting glucose should be < 5.6 mmol/L. If the level of fasting
glucose is 5.6 to < 7 mmol/L, it should be considered as
impaired fasting glucose.]
 Classification of DM
Diabetes mellitus is usually divided into following
types-
 Type 1 diabetes mellitus
 Type 2 diabetes mellitus
 Other specific types, e.g.
- Endocrine disorders
- Drug or chemical induced
- Diseases of the exocrine pancreases
- Some others
 Gestational diabetes mellitus
 Type 1 diabetes mellitus
• This type accounts for only 5-10% of diabetes previously
named as insulin dependent diabetes. It tends to occur in
the young, although it can occur at any age. It is caused
by autoimmune destruction of the beta cells in the
pancreas resulting in the absolute deficiency of insulin
production. So, for survival they need to treat by only
insulin.
• In this form of diabetes, the rate of beta cell destruction is
quite variable, being rapid in some individuals (mainly
infants and children) and slow in others (mainly adults).
This is not related to strong family history (genetic link) but
some environmental factor and viral infection trigger the
process. In some type 1, no evidence of autoimmunity is
found. We do not know how total β-cell is damaged in this
group.
 Type 2 diabetes mellitus
• Most all of our patients are in this class. Previously this
was termed as non-insulin dependent diabetes (NIDDM).
In comparison to type 1, here patients have insulin
resistance and usually have relative insulin deficiency.
Most of the patients have positive family history. They are
obese or normal weight, middle age with a history of
physical inactivity.
 Other specific types
• This type covers a group of diabetes where
hyperglycemia is caused by some factors such as drug,
diseases or genetic syndromes. Some examples are-
 Hormonal diseases- Cushing’s syndrome, thyrotoxicosis,
acromegaly, pheochromocytoma
 Drugs/toxin- glucocorticoid, diuretics, vacor
 Pancreatic diseases- chronic pancreatitis, FCPD (Fibro
Calculas Pancreatic Diseases)
Clinically this type of diabetes shows features of both
diabetes and underlying causes.
 Gestational diabetes mellitus
(GDM)
• GDM is defined as any degree of glucose intolerance
with onset or first recognition during pregnancy. So, some
unrecognized type 2 may label as GDM, and they may
need treatment after delivery. Some patients of this class
become normal afterwards. Woman having history of
GDM, are at increased risk of developing GDM in
subsequent pregnancies and ultimately becoming
diabetes later on.
 General characteristics of type 1
and type 2 diabetes
Characteristics Type 1 Type 2

Immunological Present Absent

markers
Age of onset <30 years >30 years

Body habitus Normal to wasted Obese

Plasma insulin Low to absent Normal to high

Acute complications Ketoacidosis HONK

Insulin therapy For survival For better glycemic control

Sulfonylurea Rx Unresponsive Responsive

Family history Less More

 Clinical symptoms of DM
• Clinical symptoms of diabetes depend on the type of diabetes
and severity of the conditions.
• Type 1 patients present with typical symptoms or with acute
complications (diabetic ketoacidosis)
Typical symptoms Atypical symptoms With some
complications
 Increased urination (polyuria)  Non-healing infection  Microvascular
 Increased thirst (polydipsia)  Infertility or repeated - Retinopathy
 Increased hunger (polyphagia) pregnancy loss - Nephropathy
 Weight loss  Undue fatigability - Neuropathy
 General weakness  Vulval itching  Macrovascular
- Cerebrovascular
- Cardiovascular
-Peripheral vascular

Interestingly 50% type 2 remains undiagnosed and when they reach physician,
about 20% cases already develop some sort of diabetes related complications.
 How symptoms develop
• After taking food especially carbohydrate is convert into
glucose and deposit in blood. Glucose is then filtered from
the blood in kidneys. Normally all the filtered glucose is
reabsorbed in the renal tubules. Thus no glucose appears
in urine. In diabetes, when glucose is present in high
concentration in blood, large amount of glucose filters
through renal tubules but the tubules are unable to
reabsorb glucose beyond a certain limit called the “renal
threshold”. When extra amount of glucose is not
reabsorbed, it passes through urine. Being an osmotically
active particle it carries extra water along with it. Thus
more urine is formed. This results in increased urination
(Polyuria).
• Excessive loss of water in the urine causes intercellular
dehydration and in turn stimulates the thirst centre called
the osmoreceptor located in the hypothalamus, which in
turn leads to increase water intake (Polydipsia).
• Glucose is important source of energy. In diabetes
mellitus, there is excessive passage of glucose in the
urine. Due to the excessive loss of this glucose, there is
increased food intake (Polyphagia).
• Due to total lack of insulin, the circulating glucose in the
blood is not utilized for metabolic process of the body.
Under these circumstances, the fat stored is mobilized for
energy purposes (Weight loss and general weakness).
 Diagnosis
OGTT (oral glucose tolerance test)
Fasting blood glucose level
Random or casual blood glucose level
 Oral glucose tolerance test
(OGTT)
• This is standard procedure throughout the
world where two samples of glucose values- at
fasting and 2 hours after 75 gm oral glucose
drink classify a person either to be a diabetic
or impaired glucose tolerance (IGT), IFG or
non-diabetic.
OGTT procedure
• Person should take any food he or she likes
and specially carbohydrate rich food (more
than 150 gm/day) at least for 3 days previous
to test.
 Fasting blood sample
• Blood sample should be given in early morning and
patient supposed to be without any kind of blood for 8-
12 hours overnight. Water is allowed but smoking, tea
and any kind of soft drinks are prohibited.

 Glucose drink
• 75 gm of glucose mixed with 250-300 ml of water is
given and drink should be completed within 5 minutes.
In case of child glucose dose is calculated by 1.75
gm/kg body weight to maximum 75 gm.
• Patient should be at rest for next 2 hours, do not smoke
or exercise.
 Second blood sample
• A blood sample is collected at 2 hours after the glucose
drink is over. All blood samples should be preserved in
sodium fluoride containing tubes.
 OGTT report reading
Inference Fasting blood sample 2 hrs after meal
(mmol/L) (mmol/L)

Normal < 6.1 <7.8

IFG (Impaired Fasting Glucose) ≥ 6.1 to <7.0 <7.8

IGT (Impaired Glucose Tolerence) ≥ 6.1 to <7.0 ≥ 7.8 to < 11.1

DM (Diabetes Mellitus) ≥ 7.0 ≥ 11.1

* WHO Expert Committee 1999

 Random Blood Glucose
(RBG)
• RBG value should be interpreted to diagnose when
typical symptoms are present. Results may be likely or
unlikely to be DM and most of the times require OGTT for
confirm the diagnosis.

Inference RBG level

DM is unlikely < 5.5 mmol/L

DM is likely ≥ 11.1 mmol/L

• Casual or Random is defined as any time of day without

regard to time since last meal. The classic symptoms of
diabetes include polyuria, polydipsia, polyphagia, general
weakness and unexplained weight loss.
 Fasting blood glucose (FBG)
• It is an easy procedure, less expensive, less time
consuming with no disturbance of daily activities and can
be performed in large population at a time. After 10-12
hours overnight fast, blood is drawn early in the morning.
If set value of venous plasma glucose is ≥ 7.0 mmol/L,
person can be labeled as diabetic, if blood glucose value
is < 5.6 mmol/L person can be labeled as normal. If lies in
between, person can be labeled to have impaired fasting
glucose.
Inference FBG level
Likely to be normal < 6.1 mmol/L
IFG ≥ 6.1 to < 7.0 mmol/L
DM ≥ 7.0 mmol/L
 Metabolic syndrome for
Insulin resistance
• If three or more of the following features are present in a
person, he is more prone to insulin resistance.
Feature Value

Waist circumference Male ≥ 102 cm

Female ≥ 88 cm
(For Asian M ≥ 90, F ≥ 80 cm)

Serum TG ≥ 150 mg/dl

Serum HDL cholesterol M- <40 mg/dl, F- <50 mg/dl

Blood pressure Systolic ≥ 130, Diastolic ≥ 85mmHg

Fasting plasma glucose (FPG) ≥ 5.6 mmol/L

 Management of Diabetes
For the management of diabetes, one should follow
the following rules-
 Dietary modifications
 Exercise
 Drug, if necessary
 Monitoring of blood glucose and other targets of
management
 Education for every step
 Discipline
 Targets of diabetes management
Variables Target
Fasting/pre-prandial plasma glucose (mmol/L) < 6.1
Post-prandial plasma glucose (mmol/L) < 8.0
Bed time plasma glucose (mmol/L) < 7.0
HbA1C (%) < 7.0
Total cholesterol (mg/dl) < 200
Triglycerides (mg/dl) < 150
LDL (mg/dl) < 100
HDL (mg/dl)
- Male > 40
- Female > 50
BMI (kg/m2) < 25
Blood pressure (mmHg) < 130/80
Less strict control of blood glucose is
appropriate for-
 Very young children
 Older people
 Persons with history of severe or repeated
hypoglycemia
 Limited life expectancy
 Presence of comorbid conditions
 Goals of dietary modification
• Eat a balanced meal.
• Take meals regularly.
• Attain & maintain desirable body weight
• Maintain blood glucose, lipid profile in the normal range
• Maintain blood pressure in target level
• Produce adequate energy to ensure normal growth and
development for children
• Change eating habits that will reduce insulin resistance in type
2 DM
• Provide adequate energy and nutrients for optimum outcome
of pregnant and lactating mother
• Provide nutritional support for older patients
• Prevent hypoglycemia in individual treated with anti-diabetic
drugs
• Prevent and treat chronic complications of diabetes
 Diet of diabetic patients
depends on many factors
• Age, sex
• Types of diabetes
• Patient’s weight
• Physical activity
• Presence or absence of complications/ other
diseases
• Pregnancy, lactation
 Proximate principles of food
• Carbohydrate- rice, bread etc
• Protein- fish, meat, milk etc
• Fat- butter, oil etc
• Vitamins and minerals
• Fiber
• Water

Composition of diabetic diet depends on

glycemic index and calorie value of a food.
 Glycemic index (GI)
• Glycemic index is a numerical system of measuring the
response of dietary carbohydrate to trigger rise in blood
glucose- the higher the number, the higher blood sugar
response.
• The GI depends largely on the rate of digestion and
rapidly of absorption.
• Different carbohydrate foods have a different glycemic
index.
Low glycaemic index Intermediate glycaemic index High glycaemic index
Lentils/ dhal Rye bread Glucose
Most fruits and vegetables Some rice (long grain) Mashed and baked potatoes
Yogurt Bananas Processed breakfast
Milk Pasta White bread
Oats Grapes White rice
 Factors affecting the
glycemic response
• Types of the sugar- glucose, fructose,
galactose
• Nature of the starch- amylase, amylopectin
• Starch- nutrient interactions, resistance starch
• Cooking and food processing
 Glycemic load (GL)
• The portion size of the carbohydrate will also
influence the glycemic response, this is
described as the glycemic load. Glycemic
load allows comparison of glycemic effect of
different foods.

GL= {Carbohydrate in 1 serving (g) x GI} / 100

 Daily distribution of
components of food
Carbohydrate Protein Fat

50-60% 10-20% 30%

 Dietary fiber: 20-35  Saturated fat: < 7% of DCI
g/day  MUFA : 10-15%
 PUFA : <10%
 Trans fat : <1%
 Cholesterol : <200 mg/day
 Carbohydrate
• Refined and simple sugars such as sugar, glucose, soft
drinks, jam, honey, sweets, cakes, chocolates etc
should be avoided because they are quickly digested,
absorbed and causes sudden rise in blood sugar.
• Sucrose can be taken upto a maximum of 10% of total
calorie.
• Complex carbohydrate such as rice, wheat, bread,
potatoes and maize are more suitable, they have less
glycemic index. They are digested more slowly and
cause less rapid rise in blood glucose level.
 Protein
• A diabetic patients should receive adequate protein.
• Animal source-provides better quality protein. Egg,
milk, meat, fish, poultry are protein rich food.
• Plant source-provides less good quality protein but
when two complementary types of plant proteins are
eaten together the quality improves. Pulses, cereals,
nuts are the source of plant protein.
 Fat
• Excessive intake of fat, especially saturated
fat can cause elevated blood cholesterol,
increasing the risk of heart diseases and
stroke.
• Intake of saturated fat should be <7% of total
fat
• Intake of trans fat should be minimized
• Dietary cholesterol intake should be <200
mg/day
 Trans fat
• Formed when liquid fats such as oils are
chemically hydrogenated
• Raises LDL cholesterol and lowers HDL
cholesterol
• Examples- baked products, biscuits, cakes.
 Guidelines for diabetic person
• Eat a variety of foods (include whole grains, fruits, vegetables
and milk)
• Emphasize on cereals, breads and other whole grain
products, fruits and vegetables
• Choose lower fat dairy products, leaner meats and foods
prepared with little or no fat
• Achieve and maintain a healthy body weight through regular
physical activity and healthy eating
• Limit sodium, alcohol and caffeine
• Eating slowly reduces your chances of overeating
• Water is a healthy, no calorie beverage. Drink plenty of it
• Eat smaller portions of food. Trim off extra skin and fat from
meat
• Avoid fried foods
• Regular exercise
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