Macronutrients and Micronutrients and Insulin Therapy

Below is the article which I have written for one of the Poster's for India Conference 2011.

Carbohydrate

Carbohydrate intake is the dietary focus of blood sugar control. Based on the individual’s glucose needs, weight status, lipid profile, and eating habits, carbohydrate intake should be individualized. For years free sugars were banned in the diets of those with diabetes, probably because it was assumed that their quick absorption might contribute to elevated blood sugars.

Starches were encouraged as substitutes. Scientific evidence is limited to support this common practice. Fruits and milk have been shown to have lower glycemic responses than most starches. Sucrose produces a response similar to common starches like rice, potato, and bread. Although various starches per gram of carbohydrate do have different effects on blood sugar, for purposes of dietary planning it is the total amount of carbohydrate consumed rather than the source that merits primary consideration. However, it should be mentioned that the effects of food on elevating blood sugars seem to far surpass the effects of their measured carbohydrate concentration.

The variation in responses to different carbohydrates stresses the importance of the patient performing self glucose monitoring to determine the quantities of specific foods that can be tolerated and allow to maintain glycemic control. In dietary planning, the frequency and choice of using sucrose-containing foods and/or concentrated sweets must be carefully weighed in the light of their low nutrient density and carbohydrate concentration. Making gram for gram carbohydrate substitutions will work, but frequently such substitutions become additions and then have a negative effect. Fruit is among the most maligned of the carbohydrates, and sometimes patients are forbidden fruit even by diabetologists. With fruits, portion sizes and total grams of carbohydrate merit strict attention. For many fruits the defined portion sizes for 15 g of carbohydrate are much smaller than generally consumed by most people. Another dietary sugar, fructose, produces a smaller blood glucose increase than sucrose and has been proposed as a “natural” sweetener. The moderate consumption of fructose-containing foods has presented no problem, but when fructose is consumed in large amounts, up to 20% of the calories, it is known to adversely effect blood lipids.

The sweeteners that have calories from carbohydrate like fruit juice concentrate, molasses, honey, and corn syrup have direct effects on blood sugar similar to sucrose and offer no advantage to persons with diabetes. Foods are also frequently flavored with the sugar alcohols: sorbitol, mannitol, and xylitol. The sugar alcohols have about one-half the calories of table sugar and a reduced glycemic response. Individuals do have different sensitivities to the sugar alcohols, and they are known to have a laxative effect in many persons. Nonnutritive sweeteners are encouraged for people with diabetes to add increased variety to their food choices. Nonnutritive sweeteners (acesulfame potassium, saccharin, aspartame, sucralose, and neotame) are approved for use according to the Food and Drug Administration (FDA).One cannot help but question if indeed they have any effect on weight status. However, no adverse effects of nonnutritive sweeteners have been demonstrated in humans after many years of usage over a wide range of dosages.Postprandial blood glucose responses are mainly affected by the quantity of carbohydrate consumed.However, the type of carbohydrate ingested also is a factor.

Significant details to review when looking at postprandial blood glucose levels are the type of food, type of starch, preparation methods used, ripeness, and amount of processing. Low glycemic diets have been a focus of much recent research, but at the current time there is not sufficient, consistent information to conclude that such diets lower the risk for diabetes or are effective in weight reduction to improve glycemic control.2 Such diets are generally rich in fiber and other important nutrients so that they can be encouraged as a component of the “healthy eating plan.”The recent meeting of the Dietary Carbohydrate Task Force of the International Life Sciences Institute concluded that many studies purporting to investigate lower glycemic index (GI) interventions actually studied lower glycemic loads (GL) that unavailable carbohydrate (e.g., dietary fiber), independent of GI, seems to have at least as big an effect on health outcome as GI itself. Lower GI and GL diets are beneficial for health in persons with impaired glucose metabolism, but it is as yet unclear what they mean for healthy persons. The larger the divergence of glucose metabolism from the norm, the larger the effect of lower GI and GL interventions.

FiberFor years fiber has received much attention for its disease prevention effects in the general population. Recently the literature is replete with articles demonstrating improved blood glucose management in both type 1 and type 2 diabetes with high-fiber diets. Fiber-rich foods such as beans or cereals with 5 or more grams of fiber per serving and fruits and vegetables are emphasized due to their nutrient content. Both soluble and insoluble fibers are encouraged in amounts similar to the recommendations for the general population (20–35 g or 14 g/1000 cal). However, it is the soluble vegetable fibers that are touted for their capacity to slow the absorption of food, inhibit glucose absorption, and bind cholesterol.

Protein
At the current time no data are available to indicate that the protein needs of persons with diabetes are different from the DRI for the general population, 0.8 g/kg of body weight. According to the Kidney Disease Outcomes Quality Initiative, 2007, for an individual with diabetes and chronic kidney disease (stages 1–4), 0.8 g/kg of body weight protein is recommended. It is acknowledged that most individuals consume above this recommended allowance.

Fats
For individuals with diabetes, less than 7% of the total calories consumed should come from saturated fat. Recommendations on total fat must be left to a matter of individualization depending on weight, lipid status, and treatment goals. People who are at a healthy weight and have normal lipid levels are recommended by the Diabetes Association to follow and slowly, over an extended time frame of 2 years, reduce their fat intake to <25–35%: saturated fat <7%, polyunsaturated <10%, and monounsaturated <20%. Less than 200 mg of dietary cholesterol daily and negligible trans-fatty acid intake is recommended. Omega 3 fatty acids from fish and other seafood are encouraged two times per week. However, it must be emphasized that most individuals with type 2 diabetes are not at a healthy weight. If weight loss is to be implemented, then total fat reduction may be advised.

Fats can easily be identified by patients and decreased to lower energy intake.Monounsaturated fats like olive oil and canola oil have been shown not to increase the LDL cholesterol and may improve glycemic control and triglyceride and HDL cholesterol levels. However, in type 2 diabetes efforts directed toward weight loss to decrease insulin resistance may be thwarted by these energy-dense oils. Plant sterols and stanol esters, also known as phytosterols, may lower blood cholesterol (total and LDL cholesterol) levels by decreasing its absorption in the intestine. These effects may be seen in amounts of ∼2 g/day. For many the texture and flavor of fat are important to eating satisfaction, but as a means of implementing weight loss and improving dyslipidemia, a decrease in total fat is suggested and specifically saturated fats are discouraged. This has resulted in the development of many calories reduced, low fat and/or fat-free products. Are such foods helpful in the achievement of weight loss and the improvement of blood glucose control? The use of foods reduced in fat or produced with a nonabsorbable fat substitute may or may not alter the composition and total calories of the diet. Alternative foods may be consumed in such quantities that can compensate for the changes in fat intake so that total energy is not reduced.

To make possible the reduction of fat in certain foods, carbohydrate may be added, but this could affect glycemic control. Fat-free baked products are a common example of foods that may not be reduced in total calories since carbohydrate if often added. Therefore, the “sugar-free” products may not be reduced in either fat or calories. Modified foods can be helpful to increase the variety of food choices, but patients with diabetes must be taught to use them wisely as an aid to calorie, fat, and carbohydrate control in order to foster compliance with their meal plans.

Alcohol
Alcohol is metabolized differently than the other macronutrients, and for people with diabetes a few words of caution are important. The general recommendations from the Dietary Guidelines advise two drinks per day for men and no more than one drink for women. It is of note that alcohol is not metabolized to glucose and can inhibit gluconeogenesis. If alcohol is not consumed with food and the patient is taking medication to lower blood glucose, hypoglycemia can result. Alcohol, if taken, should be taken with food. To make a caloric adjustment for alcohol intake, each beverage (12 oz beer, 5 oz wine, or 11/2 oz distilled spirits) is best equated to two fat exchanges from the diabetic meal plan. Caution should be used when combining alcohol with other beverages that contain carbohydrates (juice, soda, etc.) for it may raise blood glucose levels.

In addition, excessive use of alcohol, consisting of three or more alcoholic beverages daily, may lead to elevations in blood glucose. Alcohol is not advised for pregnant women, those with a history of alcohol abuse, and the elderly who may have problems with balance and coordination. For people with diabetes and other medical problems like pancreatitis, elevated triglycerides, or neuropathy, the consumption of alcohol is discouraged. The use of alcohol is also contraindicated with certain medications, particularly metformin which is frequently prescribed for type 2 diabetes, since alcohol can increase the effects of metformin on lactate metabolism which increases the risk of lactic acidosis. The effect of alcohol consumption on diabetes has recently been reviewed.

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Micronutrients: Vitamins and Minerals
As the general population, persons with diabetes have no need for vitamin and mineral supplementation when the dietary intake is adequate. However, the assessment of an adequate dietary intake requires training and consumes professional time. Many physicians prescribe a pill containing the reference dietary intake (RDI) of the established vitamins as an “insurance policy.” For the elderly with reduced energy intake, a multivitamin supplement is commonly given. With the increased risk for heart disease and its adverse outcome in persons with diabetes, antioxidants may be prescribed, but there is little evidence that this practice is beneficial. Routine supplementation with C, E, and carotene is not advised because of the lack of evidence of efficacy and safety concerns when used on a long-term basis. Of the minerals, calcium supplementation is frequently advised, particularly after menopause for women, since dietary calcium may not be sufficient, but as for all the other vitamins and minerals the recommendations are similar to those for the general population. Chromium has been encouraged because of its positive metabolic role particularly in type 2 diabetes. However, its use remains a topic for research and theDiabetes Association does not support its use as beneficial to glycemic control. Most people with diabetes have not been found to be chromium deficient unless they have been receiving chromium-deficient parenteral nutrition. Magnesium is acknowledged for its role in insulin sensitivity and its deficiency can contribute to carbohydrate intolerance; however, only when low serum magnesium levels can be established is repletion with magnesium appropriate. The use of diuretics may result in potassium loss that requires supplementation.

Which micronutrients control insulin resistance and diabetes complications?

You may be wondering how vitamins and minerals do this work, or which micronutrients are the most effective at protecting you from insulin resistance and diabetes. Though we can’t delve into all the science here, if you’re interested, you may want to pursue the answers to your questions by following us or drafting an email to us or just by fingering your words below.Here’s a quick overview of just a few of the important vitamins and minerals to consider.

• Chromium has long been known to support insulin function. A review of recent studies shows that a specific form of chromium, known as chromium picolinate, produced beneficial effects in over 1500 diabetes patients. It reduces blood glucose, fasting insulin, cholesterol and lipid levels, making patients less dependent on diabetic medications and reducing their risk for disease complications.

• Magnesium is a key factor in the regulation of insulin and is one of the most common micronutrients found to be depleted in the cells and bloodstream of insulin resistant and type 1 and type 2 diabetes patients. It also tends to be lower in individuals who are under stress. A recent study that followed over 85,000 women and 42,000 men showed that intake of magnesium decreases the risk of getting type 2 diabetes. Moreover, this finding was independent of the subjects’ other risk factors, which means that adequate magnesium stores appear to govern diabetes risk despite your BMI, level of activity, or family history!

• Manganese. Why lower than normal levels of manganese found in diabetic people is not well understood. Some researchers think diabetes may cause the lower levels, while others that the lower manganese levels may cause the diabetes. Manganese may help protect LDL, the “bad” form of cholesterol, from becoming oxidized, the state in which it can lead to plaques in the arteries. Fortunately, manganese is a trace element that is easily found in food sources, but more research is needed to clarify how supplementation can help with diabetes and insulin resistance.

• B vitamins Over the years, I have found B vitamins to be deficient in many of my patients. Two of the biggest factors causing low levels of B vitamins in women are stress and birth control pills.
  
  Vitamin B3 (niacin or nicotinamide). Hundreds of reactions in the body require nicotinamide, and it is vital for normal carbohydrate, fat, and protein metabolism. The large European Nicotinamide Diabetes Intervention Trial was designed to evaluate the potential of this form of vitamin B3 to halt or delay the development type 1 diabetes. Although it was not found to prevent type 1 diabetes, subsequent research on people at risk for type 1 diabetes indicates that nicotinamide does play a key role in immune regulation. It does this by reducing levels of a signaling molecule known as IFN-gamma. The links are not altogether clear, but this signaling compound has been implicated at multiple points in the progression of autoimmune diabetes.
  
  Vitamin B6 (also known as pyridoxine) can protect you from diabetes related complications. It may also be able to improve glucose tolerance, particularly in gestational diabetes.
  
  Adequate levels of B6, B9 (folate), and B12 are necessary for normal metabolism of homocysteine. High levels of homocysteine cause metabolic dysfunction and are a major risk factor for overall mortality in type 2 diabetics. Low levels of folate can be a special problem in individuals with a certain genetic variation known as MTHFR, which regulates folate metabolism. Up to 18% of the US population may have this variant, which places them at risk for complications related to inadequate folate. This can be addressed by supplementing the diet with bioavailable forms of folate.
  
  Vitamin B12 (cobalamin) is necessary for nerve cells to function properly. Ensuring adequate levels in the blood may help to prevent the nerve damage (known as peripheral neuropathy) that occurs with diabetes.

• Vitamin C (ascorbic acid) has protective effects on the kidney, as well as the eyes and the nerves. In people with diabetic hyperglycemia, it has been shown to prevent accumulation of a kind of sugar known as sorbitol that can lead to complications with these organs. Diabetics are found to accumulate high levels of sorbitol, leading the cells to “leak” important nutrient molecules such as vitamins, minerals, and amino acids. Summarizing the results of a clinical trial on insulin-dependent diabetes mellitus (IDDM), researchers considered vitamin C to be superior in normalizing sorbitol levels to drugs designed for the same purpose.

• Vitamin E is an important antioxidant that neutralizes the damaging free radicals produced during hyperglycemic states. Research findings on the value of vitamin E supplementation in preventing type 2 diabetes (primary prevention) are mixed, but have shown that people with vitamin E deficiency may be at a higher risk of developing it. Other trials do indicate that vitamin E supplements can reduce oxidative stress and improve glycemic control in patients who already have diabetes that is, for secondary prevention). Adding vitamin E to your diet may also prevent possible degenerative effects associated with vulnerable organs, such as the kidney.

There are many other micronutrients currently under study in nutrigenomics, and many more waiting to be discovered. The above list describes just a few of the many thousands of ways micronutrients can help ward off and diminish the damage that chronic diseases like diabetes can wreak in the body. In reality we have so much more to learn about how they work, and how we can determine our unique individual needs on a daily basis.

So how much is enough?

Presently there remains far too much variability in the way researchers have designed their studies — and in individuals’ own glucose control — to allow for set nutrient recommendations for everybody with insulin resistance and diabetes. Another complication is that the body’s pool of some micronutrients is so tiny that it’s very hard to assess how much an individual has or needs.Yet many healthcare providers are genuinely interested in full well-being for their patients and remain open to nutritional therapy for those at risk of insulin resistance and its ensuing complications. And in time, we expect a better understanding of how and why micronutrient therapy works.we and our patients along Personal Program members have enjoyed the benefit of a nutritionally-based model for many years. We encourage all women to focus on a whole foods diet. But given that few of us have the time and resources to achieve dietary perfection, most of us can certainly benefit from vitamin and mineral supplementation. And again, whether you have a problem with insulin resistance or you’ve been diagnosed diabetes, we urge you to find a holistic nutritional counselor or experienced dietician with a grounding in functional medicine to design a program that’s best for you.When choosing your vitamin and supplements, be sure you pick one that’s manufactured under strict quality guidelines to ensure that your body receives all the above micronutrients in adequate amounts. This can go a long way towards providing you a life free of the avoidable complications of insulin resistance and diabetes.

Summary
Exogenous insulin was the magic tool developed for the treatment of type 1 diabetes, but even with this tool, the dietary component of treatment for diabetes remains at the forefront of both effective intervention and the prevention of disease progression for all patients. Diabetes remains a dreaded disease for its feared restrictions on the total life of an individual and the modifications of lifestyle required for glycemic control and to prevent disease progression.

It must be stressed that the foods recommended for a person with diabetes are those advised for all to be in good health and to avoid the weight-related illnesses. Food selections have been clearly defined in the consensus statement of the Diabetes Association. The challenge remains to assist patients to comply with these recommendations by modifying their food choices and behaviors regarding food consumption and exercise

Stay Aware Stay Care