Most so called sugar free products are full of sugars that may not promote tooth decay but most certainly will raise your blood sugar.Here is a list of some of the sugars you may find in the sugar free products.All of these will raise your blood sugar.
1,Carob 2,honey 3,saccharose 4,corn syrup 5,lactose 6,sorbitol 7,dextrin 8,levulose 9,sorghum
10,dextrose 11,maltose 12,treacle 13,dulcitose 14,mannitol 15,turbinado 16,fructose 17,mannose
18,xylitol 19,glucose 20,molasses 21,xylose
Some ,such as sorbitol and fructose, raise blood sugar more slowly than glucose but still too rapidly to prevent a post prandial blood sugar rise in diabetics.
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Proper Nutrition to face Diabetes
Food Pyramid
Food Pyramid goup
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When you eat food that contains carbohydrates, the sugar (glucose) from the food breaks
down during digestion and gives you energy. After you eat,
your blood glucose level rises; the speed at which the food is able to increase your blood glucose level is called the "glycemic response." This
| Food Pyramid goup | Servings | Nutrient in serving | Healthy Choices |
| Group | per day | serving | |
| Meats,meat- | 2 to 3 | 21 grams of protein | fish,white meat chicken or |
| substitute | and no carbohydrate; | chicken or turkey | |
| and other protiens | aim for | red meat,reduced fat | |
| lean ones | or fat-free | ||
| Milk and | 2 to 3 | 12 grams of carbo | low-fat of far-free milk and |
| byproducts | hydrate8 grams of | fat free withartificial sweete- | |
| protien;aim for low fat | ner. | ||
| Fruits | 2 to 4 | 15 grams of | Whole fresh fruits |
| carbohydrates about | |||
| 60calories and no fats | |||
| Vegetables | 3 to 5 | 5 grams of | fresh vegetables or frozen |
| carbohydrate | vegetables without sauce | ||
| and no fat | butter,or margarin | ||
| Breads,grains,and | 6 to 11 | 15 grams of carbo- | whole-grain breads and |
| other starches | hydrates,3 grams of | cereals or tortillas,oatmeal, | |
| protien and up to | bulgur,brown rice,dried bean | ||
| 1gr fat | lentils,peas,yams,and | ||
| butternut squash,pumpkin. |
Carbohydrates counting
Carbohydrate
(carb) counting can be very
helpful in dosing rapid-acting insulin with meals, controlling blood
sugar levels, and aiding
in weight loss. The grams of
total carbohydrate are listed on the
nutrition facts food label and people are taught to read labels
and check grams of total carbohydrate. Carb
counting is fairly simple when foods have a food label, but it can
be more challenging
when eating out or eating mixed dishes
When ordering pasta or rice at a restaurant it may be difficult to estimate exactly how much you are eating. The very first task when you start carb counting is to measure all the food you eat at home. One cup of cooked pasta or rice contains 45 grams of total carbohydrate. After you measure out this portion size a few times, you will see what it looks like
on
your plate and this will help you estimate portion sizes when eating out. You
will soon realize that you are
probably receiving 3 or more cups of cooked pasta when eating at
many restaurants.
It may be difficult to
estimate the carb content of meals
that contain a variety of foods such
as casseroles, lasagna, and chili. In general 1 cup of a casserole dish, such as tuna noodle casserole, can contain between 25-30 grams of total carbohydrate. One cup of chili contains approximately 25 grams carbohydrate.
Section your plate
When you sit down for a meal, draw an imaginary line through the center of your plate.
Draw a line to divide one section into
two:
- About
one fourth of your plate should be filled with grains or
starchy foods, such as rice, pasta, potatoes, corn, or peas.
- Another fourth should be protein (foods, like meat,
fish, poultry, or tofu).
- For the other half of your plate, you can fill it with non-starchy vegetables, like broccoli, carrots, cucumbers, salad, tomatoes, and cauliflower.
Then, add a glass of non-fat milk, and a small
roll or piece of fruit and you are ready
to eat!
You may need to count the carbohydrates or exchanges in your meal, so you can be sure your
insulin and exercise are on target.
Health Issues
Choose Carefully when shopping Read labels. Limit products high in corn syrup, molasses, honey, or ingredients ending in "ose" (like fructose, sucrose, and dextrose). These
are all types of sugar.
Look for foods that are low in fat. Avoid products packed in oil, fried food, fatty meats, and foods prepared with creamy sauces
or butter.
To avoid being tempted by unhealthy snacks, avoid the candy and snack food aisles.
Cook Wisely
When you cook, try to
cut down on sugar and fat. If you
have high blood pressure, cut down on salt as well.
Instead of frying, broil, bake, or grill. Instead of cream-based sauces or sugary glazes, flavor foods with vegetable puree, lemon or lime juice, or herb seasonings. Remove skin from chicken and turkey before you
serve it.
Glycemic Index of foods
It is a good idea to
get to know and understand the
Glycemic Index, because choosing foods
with a low GI rating more often than choosing
those with a high GI may help you get a better control.
The Glycemic Index is a scale that ranks carbohydrate-rich foods by how much they raise blood glucose levels compared to glucose or white
bread.
The glycemic index
should not be your only criterion when
selecting what to eat. The total amount of carbohydrate, the amount and type of fat, and the fiber and salt content are also important dietary considerations. The glycemic index is most useful when deciding which high-carbohydrate foods to eat. But don't let the glycemic index lull you into eating more carbohydrates than your body can handle. The number of grams of carbohydrate we consume is awfully important. Make sure you know the carbohydrate content of the foods you eat by studying the nutritional information on
the package
glycemicresponse is influenced by many factors, including how much food you eat, how much the food is processed or even how the food is prepared (for example, pasta that is cooked al dente — or firm — has a lower glycemic response than pasta that is overcooked). Factors such as variety, cooking, and processing
may effect a food's GI.
Foods that raise your
blood glucose level quickly have a
higher GI rating than foods that
raise your blood glucose level more slowly. In general, the lower the rating,
the better the quality of carbohydrate.
Try to choose low and medium GI foods more often than high GI foods. A GI of 55 or less ranks as low, a GI of 56 to 69 is medium, and
a Cl of 70 or more ranks as high.
You can predict the
glycemic index of a mixed meal. Simply
multiply the percent of total
carbohydrate of each of the foods by its glycemic index and add up the results to get the glycemic index
of the meal as a whole.
If you choose a high GI
food, combine it with a low Cl food,
for an overall medium GI meal. For
example, half a bagel (high GI) with a
bowl of chili (low GI) , or corn flakes cereal (high GI) topped with a spoonful of All Bran (low GI) and some
strawberries (low Cl(.
Tips to help you
lower the Glycemic Index of your daily meals:
Try to choose at least one low Cl food at each
meal
Limit the amount of processed, refined starchy foods, as they tend to be low in fibre and
other nutrients and have a higher GI.
Try new foods that have a low GI. Experiment with beans, legumes and lentils by including them in dishes such as chili, soups
and salads.
Choose parboiled, brown or white rice mere
often than instant rice.
Eat pasta, rice, yams, lima beans or baked potatoes more often than mashed, boiled or instant
potatoes. Eating potatoes cold, as in a salad, reduces their GI
Use vinaigrette instead of a creamy salad dressing. It's lower in fat, plus the acidity of the vinegar slows digestion, lowering the meal's
GI.
Watch your portion sizes; the bigger the portion, the more it will increase your blood glucose, regardless
of its GI rank.
Glycemic Index
Diabetes Eating Plan
Type-2 Diabetes Management
New Page 1
Modern
management of
Type 2 diabetes mellitus
Introduction
Diabetes mellitus is a common disorder, of increasing prevalence. Patients with Type 2 (formerly `non-insulin-dependent' or 'maturity-onset') diabetes mellitus are not prone to ketoacidosis and do not necessarily require treatment with insulin. Two to three percent of British people of Caucasian origin have diabetes mellitus, and of these 80-90% have Type 2 disease. However, among Asian and Afrocaribbean adults, the prevalence of Type 2 disease is as much as ten times higherl.
Since the morbidity and mortality of Type 2 diabetes mellitus are high, and because effective methods of preserving health and reducing early mortality are limited, the logistics of management present one of the most challenging public health problems of our generation.
Aims of management
The first concern in treating all patients is to alleviate symptoms and enhance quality of life. Thereafter, treatment (see Table 1) aims to minimise the development of long-term complications and reduce early mortality.
Treatment goals
Glycaemic control eliminates symptoms and, in the longer term. delays the development of complications. The United Kingdom Prospective
Table 1: Requirements for treating Type 2 diabetes
mellitus
Optimal glycaemic
control
Tight control of
hypertension, which provides very substantial benefits
Reduction of other risk-factors
for macrovascular disease (smoking, lipids, lack of exercise)
Early detection of complications
and prevention of their progression
Diabetes Survey (UKPDS)
of Type 2 diabetes mellitus demonstrated the benefits of establishing tight
control on microvascular complications in this
group of patients - namely, 25% reduction of retinopathy and reduced development of microalbuminuria2.
Optimal results are obtained (as in Type I disease) if an HbAIC
of 7% or less can be achieved using any of the conventional treatments (insulin
per se does not confer any additional advantage), though UKPDS demonstrated the
increasing difficulty in obtaining such
optimal control. As the benefits are only evident after a decade of good
control, it is only likely to help patients who
are expected to live for ten years or more and they need to be willing
to comply with treatment and undertake lifestyle changes which are not always
easy. It is crucial to agree on the target suitable for an individual patient,
and then to monitor its achievement. Achieving
glycaemic control
Blood glucose concentration is controlled by healthy eating,
addition of oral hypoglycaemic agents and introduction of insulin. Because Type
2 diabetes mellitus is a progressive
disease'- it is usually necessary to adopt these approaches in sequence.
Failure of glycaemic control
The progressive nature of Type 2 diabetes mellitus means that with the passage of time, control becomes more difficult, and treatments required to maintain optimal control become increasingly complex. Treatment failures leading to a need for insulin occur at approximately 2% annually for obese patients and 6% annually for those of lean physique. Research studies show that a minority of patients have islet-cell antibodies, potentially having Type I (`insulin-dependent') diabetes mellitus.
If symptoms of diabetes mellitus persist or individualised targets of control cannot be met, ie, when the existing mode of treatment is deemed to have failed, treatment needs to be stepped up.
Assessment of diabetic control
When symptoms have been eliminated, good diabetic control is assessed by HbA 1 C level, which should be measured at least twice annually. Ideal control is only likely if blood glucose concentration is monitored by a patient who is motivated and able to do so. Urine testing is adequate for those in whom tight control is a less pressing need, or for those who cannot cope with the more complex techniques of monitoring or their interpretation. The most simplistic approach is to aim for a fasting blood glucose concentration of 6 mmol/L', although for those on oral hypoglycaernics, insulin or both, post-prandial assessments are also needed for appropriate adjustment of treatment.
Treatments
Healthy eating and exercise
Diet is the cornerstone of diabetic treatment and. in Type 2 diabetes mellitus. it should always be tried alone before medication is considered. normally for at least three months. Details of appropriate diets are described in all standard texts. Dieting aims to reduce the weight of the obese patient: poor control of diabetes persisting in the face of weight gain is clear evidence of dietary non-compliance and careful consideration must be given to this before further medication is recommended.
The
importance of increasing physical activity in the management of Type 2
diabetes mellitus is now widely accepted, serving to reduce body weight and to increase insulin sensitivity. Even a
brisk walk of a mile every day confers
some benefit, but physical disability or advanced age often preclude
this.
Oral hypoglycaemic agents
These
are introduced when dietary treatment alone has failed (see Table 2). The need for these agents, and their dose,
should be monitored through life as there are times when the dose may be
reduced or, indeed, medication stopped altogether.
Sulphonylureas
Introduced
into clinical practice in 1957, these have proved safe and effective. They represent first-line oral
treatment for non-obese patients. It is pointless to use more than one,
and none is ultimately more effective than
another. However, it is now usual not to use longer acting sulphonylureas (eg, chlorpropamide and
glibenclamide) in those aged over 70
years because of the risk of serious hypoglycaemia. In patients with renal failure, it is best to use
sulphonylureas which are not excreted as
active compounds by the kidney, eg, gliclazide, glipizide and tolbutamide.
Otherwise, choice of sulphonylurea is based on personal preference, knowledge of the drug, and its cost. Chlorpropamide, though available, is no longer widely used - it
has a very long half-life, a greater
risk of hypoglycaemia, especially in elderly patients, and can provoke
an unpleasant facial flush after ingestion of alcohol.
Table 2: Oral hypoglycaernic agents
Daily dosage range (mg) minimum-maximum
Sulphonv lureas
|
Glipizide |
2.5-30 |
|
Gliclazide |
40-320 |
|
Tolbutamide |
500-2000 |
|
Glibenclamide |
2.5-15 |
|
Glibornuride |
12.7-75 |
|
Tolazamide |
100-750 |
|
Gliquidone |
15-180 |
|
Glimepiride |
1-4 |
Biguanide
Metformin 1000-2000
Alpha-glucosidase inhibitor
Acarbose 50-300
Other
Repaglinide 1.5-16
Glimepiride is a relatively new sulphonylurea
designed to be used once-daily;
it is suggested that it may provoke less hypoglycaemia than glibenclamide3.
Repaglinide, recently introduced, is a very
short-acting oral hypoglycaemic
agent whose effect is mediated by inhibition of ATP-dependent potassium ion channels4. It
is intended to improve postprandial
insulin profiles only and therefore is only taken before meals. and not if they are omitted. It may, in theory,
cause less hypoglycaemia, though this has not
been established.
Biguanides
Metformin
is the only biguanide available in the UK. It is the treatment of choice in obese diabetic patients in whom diet
and exercise treatments have failed. Its
chief advantage is that glycaemic control is improved, with
significantly less weight gain than when sulphonylureas are used. It does not
cause hypoglycaemia in therapeutic dosage.
Metformin should not be used in patients with renal
failure or liver disease, in elderly
people, or those in whom there is a risk of any state of shock (eg, those with serious heart disease) or
people with a very high alcohol intake, because of the risk of serious
lactic acidosis.
Diarrhoea, and nausea - sometimes
accompanied by a curious metallic taste - are not uncommon when metfonnin
treatment is started, but may resolve with
time. A small initial dose (for example, 500 mg twice-daily) and a gradual increase in dosage, make
gastrointestinal adverse effects less likely. Malabsorption syndromes
have been reported5.
Other agents
Carbohydrate absorption can be reduced (and,
thereby, also postprandial
hyperglycaemia) by inhibiting enzymes responsible for breaking down complex carbohydrates, eg by acarbose
which has a weak hypoglycaemic effect.
It can be used in combination with other oral hypoglycaemic agents and
slightly decreases HbAIc. The severe
flatulence which it often causes
deters many from using it.
Thiazolidinediones, oral agents which increase insulin
sensitivity6, are marketed in
other countries, and are likely to be re-introduced here. Their
potential use is for patients with insulin-resistant Type 2 diabetes mellitus,
ie, those who are obese, often also with hypertension and hyperlipidaemia. Newer
formulations should avoid the problem of hepatotoxicity which led to the
withdrawal of the first drug of this type introduced in the UK.
Drug
interactions
Alcohol
can cause serious hypoglycaemia when used with sulphonylureas, and lactic acidosis in those taking metformin. Major interactions between sulphonylureas and other drugs
are uncommon, but can cause
hypoglycaemia, eg, with sulphonamides (including cotrimoxazole), azapropazone, and azole antifungal
agents. The manufacturers of the anti-obesity
drug orlistat advise that it should not be prescribed with metformin or acarbose. Serious hyperglycaemia is produced by corticosteroids, dopexamine and
intravenous betaadrenergic agents eg,
salbutamol, terbutaline and ritodrine. Thiazide diuretics (other than at minimum dosage eg, bendrofluazide 2.5 mg) can significantly
exacerbate hyperglycaemia.
Other,
less common, adverse drug interactions are described elsewhere7.
Drug
combinations
Any of the above oral
hypoglycaemic drugs can be used in combination and at least two agents are often needed. Thus, when diet with metformin has failed to establish optimal
glycaemic control sulphonylureas can
be added, insulin may be needed (though there are problems from weight gain and hypoglycaemia) and
addition of acarbose may have a small
effect. A subgroup analysis of data from UKPDS indicating that possible harm might result from combining metformin and a sulphonylurea8 has not
been substantiated, and this drug
combination continues to be valuable in the control of Type 2 diabetes
inellitus mellitus.
Indications for insulin
in Type 2 diabetes inellitus
Deciding when to use
insulin in Type 2 diabetes mellitus remains one of the most important, yet one of the most difficult
aspects of the management of these
patients9. Failure to use insulin in some, especially those of lean physique, results in protracted and
needless malaise if not actual danger.
On the other hand, the inappropriate use of insulin can cause damaging
weight gain, hypoglycaemia or both. Age is no bar to
the use of
insulin and the argument not to use it because of excessive age can cause great harm. After ensuring, as far as possible,
that existing treatment is properly taken, the
indications for use of insulin in Type 2 diabetes
mellitus10 are shown in Table 3 and Figure 1.
Insulin
and oral hypoglycaemic agents
Combining insulin
treatment with trtetfortnin helps to diminish the amount of the inevitable weight gain in overweight
patients9. Combining it with sulphonylureas
may decrease the amount of insulin actually needed
and enhance the use of a single night-time insulin dose, but
overall the clinical advantages of this combination are small.
Table 3:
Indications for insulin
in Type 2 diabetes mellitus
Continuing weight
loss (even if insidious), persistent symptoms or both. Insulin treatment in
these patients almost always results in a substantial improvement in well-being.
Non-obese patients without symptoms but with poor
diabetic control, whose weight is stable and who are conscientious with
existing treatment.
Obese patients without symptoms but whose weight
is stable present a dilemma: the correct
treatment is intensification of diet, but a few of these patients will benefit from insulin. A three month trial of insulin can
be very valuable in determining its efficacy in the individual patient.
Insulin
is often required in patients with intercurrent illness. Withdrawal of insulin after recovery from the illness is important
provided adequate control is achieved and maintained.
The
development of early diabetic complications or hyperlipidaemia strengthens the decision
to tighter control by starting insulin treatment.
If pregnancy
is planned, patients should always be changed to insulin treatment.
Other
risk-factors
Management
of cardiovascular risk-factors is crucial, especially in patients with Type 2 diabetes mellitus in whom the
chief causes of both morbidity and mortality are cardiovascular.
Blood pressure control is paramount, as confirmed by
UKPDS, angiotensin-converting-enzyme
inhibitors and beta adrenoceptor antagonists
are equally effective' 1. Active treatment, which aimed
to achieve a blood pressure less than 150/85
mmHg and which actually reduced the
average blood pressure to 144/82 mmHg, produced a 37% reduction of microvascular end points, especially
the need for photocoagulation, a 32%
reduction of diabetes-related deaths and a 44% reduction in strokes12. Advice on smoking, weight reduction,
and control of blood lipid concentrations are also important facets of
diabetic
management.
Diabetic
complications
It
is crucial to screen for major complications, particularly damage to the eyes, feet and kidneys, and to treat complications
if they are found. As long as
primary prevention by `tight control' remains difficult, preservation of vision and kidney function and
integrity of the feet will gain more from these specific measures than from our
often inadequate techniques of `control'.
Conclusions
• Type 2 diabetes mellitus is a progressive disease which
becomes increasingly
difficult to treat.
• Good control of hypertension and
blood glucose concentration reduce complications and early mortality, but their
benefits may only be
apparent after several years.
• Selection of appropriate patients who will benefit from
intensive
management is crucial.
• Screening for and management of diabetic complications
is effective and remains
an integral part of diabetes care.
References
1.
Amos AF,
McCarty DJ, Zimmet P. The rising global burden of diabetes and its
complications: estimates and projections to the year 2010. Diabet Med 1997; 14 (suppl
5): S 1-85.
2.
3. Langtry HD, Balfour JA. Glimepiride. A review of its use in the management of type 2 diabetes mellitus. Drugs 1998; 55: 563-84.
4.
5.
Adams JF, Clark JS,
6.
Kumar S, Prange A, Schulze J, Lettis S, Barnett AH.
Troglitazone, an insulin action
enhancer, improves glycaemic control and insulin sensitivity in elderly type
2 diabetic patients. Diabet Nled 1998; 15: 772-9.
7.
British
Medical Association and Royal Pharmaceutical Society of
8.
9. Birkeland KI. Improving glycaemic control with current therapies. Diabet Med 1998: 15 (suppl 4): S 13-19.
10.
Joint
Working Party of the British Diabetic Association, the
11.
12.
Prescribers'
Journal 2000 Vo1.40 No.]
