تغذيه و ديابت

امين صالحي ابرقوئي

دانشکده بهداشت

دانشگاه علوم پزشکي شهيد صدوقي يزد

Chronic Diseases result in

percent of deaths4444

52525252 ٢

CardiovascularCardiovascularCardiovascularCardiovascular Chronic RespiratoryChronic RespiratoryChronic RespiratoryChronic RespiratoryDiseaseDiseaseDiseaseDisease

Type Type Type Type 2222 DiabetesDiabetesDiabetesDiabetes CancerCancerCancerCancer

Diabetes definition٣

Metabolic disorder of multiple etiology

(causes) characterized by hyperglycemia with

carbohydrates, fat, and protein metabolic

alterations that result in defects in the

secretion of insulin, its action or both.

٤

٥

Global Prevalence of

Diabetes

٦

Global Prevalence Estimates, 2000 and 2030

2030 4.4 %

0.0% 1.0% 2.0% 3.0% 4.0% 5.0%

2000

٧

2.8 %

Reference: Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes. Diabetes Care. 2004; 27(5): 1047-1053.

Diabetes in the World٨

India

3131..77

China

2020..88

1717..77

YearYearYearYearYearYearYearYear20002000200020002000200020002000

millions

India

USA

1717..77

Indonesia

88..44

Japan

66..88

Reference: Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes. Diabetes Care. 2004; 27(5): 1047-1053.

Diabetes in the World٩

India

7979..44

China

4242..33

3030..33

YearYearYearYearYearYearYearYear20102010201020102010201020102010

millions

India

USA

3030..33

Indonesia

2121..33

Japan

88..99

Reference: Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes. Diabetes Care. 2004; 27(5): 1047-1053.

Prevalence of Diabetes by Country١٠

11.0

7.47.1 7.0

5.0

Prev

ale

nce (

%)

Prev

ale

nce (

%)

Puerto Rico

(2003)*

Australia

(2002)**

United

States

(2003)*

Arabia

(1999)***

Alaska

(2003)*

* > 18 years only. Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System 1999-2003. Atlanta,

GA: United States, Department of Health and Human Services.

** Dunstan DW, Zimmet PZ, Welborn TA, Courten MP, Cameron AJ, Sicree RA, et al. The raising prevalence of diabetes and

impaired glucose tolerance. Diabetes Care. 2002; 25(5): 829-834.

*** Warsy AS, el-Hazmi MA. Diabetes mellitus, hypertension and obesity-common multifactorial disorders in Saudis. Eastern

Mediterranean Health Journal. 1999; 5(6): 1236-42.

Prevalence of Diabetes in Adults Prevalence of Diabetes in Adults Prevalence of Diabetes in Adults Prevalence of Diabetes in Adults United States, BRFSSUnited States, BRFSSUnited States, BRFSSUnited States, BRFSS

1990

Reference: Mokdad et al., Diabetes Care 2000;23:1278-83.

No Data <4% 4%-6% 6%-8% 8%-10% >10%

١١

1991-92

Prevalence of Diabetes in Adults Prevalence of Diabetes in Adults Prevalence of Diabetes in Adults Prevalence of Diabetes in Adults United States, BRFSSUnited States, BRFSSUnited States, BRFSSUnited States, BRFSS١٢

Reference: Mokdad et al., Diabetes Care 2000;23:1278-83.

No Data <4% 4%-6% 6%-8% 8%-10% >10%

1993-94

Prevalence of Diabetes in Adults Prevalence of Diabetes in Adults Prevalence of Diabetes in Adults Prevalence of Diabetes in Adults United States, BRFSSUnited States, BRFSSUnited States, BRFSSUnited States, BRFSS١٣

Reference: Mokdad et al., Diabetes Care 2000;23:1278-83.

No Data <4% 4%-6% 6%-8% 8%-10% >10%

1995-96

Prevalence of Diabetes in Adults Prevalence of Diabetes in Adults Prevalence of Diabetes in Adults Prevalence of Diabetes in Adults United States, BRFSSUnited States, BRFSSUnited States, BRFSSUnited States, BRFSS١٤

Reference: Mokdad et al., Diabetes Care 2000;23:1278-83.

No Data <4% 4%-6% 6%-8% 8%-10% >10%

1995

Prevalence of Diabetes in Adults Prevalence of Diabetes in Adults Prevalence of Diabetes in Adults Prevalence of Diabetes in Adults United States, BRFSSUnited States, BRFSSUnited States, BRFSSUnited States, BRFSS١٥

Reference: Mokdad et al., Diabetes Care 2000;23:1278-83.

No Data <4% 4%-6% 6%-8% 8%-10% >10%

1997-98

Prevalence of Diabetes in Adults Prevalence of Diabetes in Adults Prevalence of Diabetes in Adults Prevalence of Diabetes in Adults United States, BRFSSUnited States, BRFSSUnited States, BRFSSUnited States, BRFSS١٦

Reference: Mokdad et al., Diabetes Care 2000;23:1278-83.

No Data <4% 4%-6% 6%-8% 8%-10% >10%

1999

Prevalence of Diabetes in Adults Prevalence of Diabetes in Adults Prevalence of Diabetes in Adults Prevalence of Diabetes in Adults United States, BRFSSUnited States, BRFSSUnited States, BRFSSUnited States, BRFSS١٧

Reference: Mokdad et al., Diabetes Care 2000;23:1278-83.

No Data <4% 4%-6% 6%-8% 8%-10% >10%

2000

Prevalence of Diabetes in Adults Prevalence of Diabetes in Adults Prevalence of Diabetes in Adults Prevalence of Diabetes in Adults United States, BRFSSUnited States, BRFSSUnited States, BRFSSUnited States, BRFSS١٨

Reference: Mokdad et al., Diabetes Care 2000;23:1278-83.

No Data <4% 4%-6% 6%-8% 8%-10% >10%

2001

Prevalence of Diabetes in Adults Prevalence of Diabetes in Adults Prevalence of Diabetes in Adults Prevalence of Diabetes in Adults United States, BRFSSUnited States, BRFSSUnited States, BRFSSUnited States, BRFSS١٩

Reference: Mokdad et al., Diabetes Care 2000;23:1278-83.

No Data <4% 4%-6% 6%-8% 8%-10% >10%

Prevalence of Diabetes in EMR٢٠

Types of diabetes:

Diagnosis of diabtes:

Type I DM

�Autoimmune or idiopathic:� B-cell destruction: rapid in children and slowly in adults

�Almost complete lack of insulin or severe lack of severe lack of

�Patients commonly lean� excessive thirst (polydipsia), frequent urination (polyurea)

� significant weight loss, dehydration, ketoacidosis.

Type I diabetes:

� Most cases are diagnosed in people younger than 30 years of age:

� Peak incidence :

� around ages 10 to 12 years in girls

� 12 to 14 years in boys� 12 to 14 years in boys

� Risk factors:

� Genetic (A trigger, likely environmental, is necessary for the expression of the genetic propensity).

� Autoimmune

� Environmental

Type I diabetes

� Frequently, after diagnosis and the correction of hyperglycemia, metabolic acidosis, and ketoacidosis, endogenous insulin secretion recovers.

� During this honeymoon phase exogenous insulin requirements decrease dramatically for up to 1 year or requirements decrease dramatically for up to 1 year or longer, and good metabolic control may be easily achieved.

� Amylin, a glucoregulatory hormone is also produced in the pancreatic B-cell and co-secreted with insulin.

� Amylin complements the effects of insulin by regulating postprandial glucose levels and suppressing glucagon secretion.

Type I diabetes

� Individuals with TIDM are also prone to other autoimmune disorders:

� Grave's disease

� Hashimoto's thyroiditis

Addison's disease� Addison's disease

� Vitiligo

� celiac disease

� Autoimmune hepatitis,

� Myasthenia gravis

� Pernicious anemia

Type II DM

� Most Common (90-95 % of all diagnosed cases of diabetes)

� It is present long before it is diagnosed.

� Strong Genetic Basis

Absence of Ketosis� Absence of Ketosis

� Insulin resistance and Inadequate Insulin Secretion

� T2DM is characterized by a combination of insulin resistance and B-

cell failure.

� Obesity is a strong factor

٢٨

Risk factors for T2DM include:

� genetic and environmental

� family history of diabetes

� Older age;

� Obesity (particularly intra-abdominal obesity)

� physical inactivity

� A prior history of gestational diabetes

� Prediabetes

� race or ethnicity.

Adiposity and a longer duration of obesity are powerful risks factors for T2DM, and even small weight losses are associated with a change in glucose levels toward normal in persons with

prediabetes.

Secondary/Other Type

� Related to certain diseases, conditions or drugs

� Known or probable cause

� Treatment of underlying disorder may ameliorate Treatment of underlying disorder may ameliorate

the diabetes

� Hyperglycemia present at level diagnostic of diabetes

Malnutrition Related Diabetes Mellitus

� Mostly in developing countries

� Among 10 to 40 year olds

� Hyperglycemia present without ketoacidosis� Hyperglycemia present without ketoacidosis

� Role of malnutrition as a causal factor is unknown.

٣٢

Gestational DM

� 2-4% during second or third trimester

� Onset of DM with pregnancy

� More common in older women with family history of

DM

� Higher chance of developing NIDDM and IGT in the next

5 to 10 years.

� Lifestyle modifications aimed at reducing or preventing weight gain and increasing physical activity after pregnancy may reduce the risk of subsequent diabetes.

GDM

� Diagnosed during the second or third trimester of pregnancy because of the increase in insulin antagonist hormone levels and normal insulin resistance that occurs at this time.

� Women at high risk should be tested during the first trimester:� Women with an A1C of greater than 6.5%

� A fasting glucose of more than 126 mg/dL (7 mmollL

� 1-hour glucose or more than 200 mg/dL (11.1 mmollL

� Had diabetes before becoming pregnant and should be treated for GDM.

� GDM is related adverse maternal, fetal, and

neonatal outcomes. Extra glucose from the mother

� Macrosomia: The fetus may become too large for a normal

birth, resulting in the need for cesarean delivery. birth, resulting in the need for cesarean delivery.

� Neonatal hypoglycemia at birth

� The above-normal levels of maternal glucose have caused the fetus to

produce extra insulin.

� GDM does not lead to fetal anomalies but diabetes prior to

pregnancy, does.

� Nutrition

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٥١

Prevention and Treatment of CVD and

Diabetes

�Omega-3 Food Sources� Preferably from both marine and plant sources, should be included in a cardio protective diet.

� Consuming dietary sources of omega-3 fatty acids from � Consuming dietary sources of omega-3 fatty acids from fish [two 4oz servings of fish per week (preferably fatty fish such as mackerel, salmon, herring, trout, sardines, or tuna)]

� Plant-based foods of 1.5g alpha-linolenic acids (1 Tbs canola or walnut oil, 0.5 Tbs ground flax seed, <1 tsp flaxseed oil) are recommended.

٥٢

Prevention and Treatment of CVD and

Diabetes

� Omega-3 Supplements

� If an individual does not eat food sources of omega-3 fatty acids, then 1g of EPA and DHA omega-3 fatty acid supplements may be recommended for secondary prevention.

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٦٢

Management of

pre-Diabetespre-Diabetes

And Diabetes

Management of prediabetes:

� Medical management:

� Metformin, a-glucosidase inhibitors, Orlistat, and Thiazolidinediones(TZDs:Rosiglitazone,Pioglitazone,Troglitazone) has been shown to decrease incidence of diabetes by various degrees.by various degrees.

� At this time, metformin is the only drug that should be considered for use in diabetes prevention. I

� t is the most effective in those with a BMI of at least 35 kg/m2 and who are younger than age 30.

� Lifestyle changes:

� Physical activity:

�Moderate intensity aerobic physical activity for a minimum of 30 minutes 5 days per week (150 min/week) (i.e., walking 3 to 4 miles/hour)

٦٥

�Vigorous-intensity aerobic physical activity for a minimum of 20 minutes 3 days per week (90 mini week)

�Muscle-strengthening activities

� Physical activity independent of weight loss improves insulin sensitivity.

Bariatric Surgery and Prediabetes

� For morbidly obese individuals

� improvement in glucose occurs rapidly and before significant weight loss

٦٦

Medical Nutrition Therapy for Prediabetes

� Food choices that facilitate moderate weight loss

� weight loss is an important goal

� Total dietary fat

and greater insulin resistance� and greater insulin resistance

� dietary fiber

� has been associated with improved insulin sensitivity

� Reduction in alcohol intake

Management of diabetes

� MNT alone is not enough to keep Al C level at 7% or less.

� Medication, and often insulin, need to be combined with nutrition therapy

� Management of all types of diabetes includes:� Management of all types of diabetes includes:

� MNT

� physical activity

� Monitoring

� Medications

� Self management education

Management goals

� An important goal of treatment is to provide the patient with the necessary tools to achieve the best possible :

� control of glycemia, lipidemia, and blood pressure

� Prevent, delay, or arrest the microvascular and macrovascular complications while minimizing hypoglycemia and excess weight gain.

� Optimal control of diabetes also requires the restoration of normal carbohydrate, protein, and fat metabolism.

٧٢

٧٣

٧٤

Medical Nutrition Therapy for Diabetes

� Carbohydrate Intake

� Low carbohydrate diets (up to 55% of total energy intake)

� foods that contain carbohydrates (whole grains, fruits, vegetables, and low-fat milk) are excellent sources of vitamins, minerals, dietary fiber, and energy---------- Choose foods with low dietary fiber, and energy---------- Choose foods with low glycemic load

� In persons with T1DM or T2DM who adjust their mealtime insulin doses or who are on insulin pump therapy, insulin doses should be adjusted to match carbohydrate intake, known as the insulin-to-carbohydrate ratios.

� Carbohydrate counting

� Exchange lists

٧٦

٧٧

Glycemic Index and Glycemic Load:

� Glycemic index (GI): relative area under the postprandial glucose curve of 50 g of digestible carbohydrates compared with 50 g of a standard food, either glucose or white bread.

� The estimated glycemic load (GL) of foods, meals, and dietary patterns is calculated by multiplying the GI by the amount of carbohydrates in each food and then totaling the values for all foods in a meal or dietary pattern.

Fiber

� Thus recommendations for fiber intake for people with diabetes are similar to the recommendations for the general public.

� Although diets containing 44 to 50 g of fiber daily improve glycemia, more than usual fiber intakes (less than improve glycemia, more than usual fiber intakes (less than 24 g daily) have not shown beneficial effects.

� Consuming foods containing 25 to 30 g of fiber per day, with special emphasis on soluble fiber sources (7-13 g) is recommended as part of cardioprotective nutrition therapy.

Simple Sugars:

� Sucrose intakes of 10% to 35% of total energy intake do not have a negative effect on glycemic or lipid responses when substituted for isocaloric amounts of starch.

Fructose:

� There appears to be no significant advantage of alternative nutritive sweeteners such as fructose versus sucrose. Fructose provides 4 kcal/g, as do other carbohydrates, and even though it does have a lower glycemic response than sucrose and other starches,

� large amounts (15% to 20% of daily energy intake) of fructose have an adverse effect on plasma lipids.

� However, there is no reason to recommend that persons with diabetes avoid fructose, which occurs naturally in fruits and vegetables as well as in foods sweetened with fructose.

Sugar alcohols

� Food and Drug Administration (FDA) include approved

� Sugar alcohols: erythritol, sorbitol, mannitol, xylitol, isomalt, lactitol, and hydrogenated starch hydrolysates)

� Tagatose. � Tagatose.

� They produce a lower glycemic response and contain, on average, 2 calories/g

� They have some side effects particularly in children.

Nonnutritive sweeteners

� Saccharin, aspartame, neotame, acesulfame potassium, and sucralose are approved by FDA.

� The ADI generally includes a 1OO-foldsafety factor and greatly exceeds average consumption levels.

� For example, aspartame actual daily intake in persons with

٨٣

� For example, aspartame actual daily intake in persons with diabetes is 2 to 4 mg/kg of body weight daily, well below the ADI of 50 mg/kg daily.

Other macronutrients:

� Protein Intake (15-20 percent)

� Dietary Fat

� Like diets to prevent CVDs:

� SFAs: lower than 10%

� PUFAs: lower than 10%

� Trans Fat: lower than 1% or zero

٨٥

Omega-3 fatty acids

� There is evidence from the general population that foods

containing omega-3 polyunsaturated fatty acids are

beneficial and two to three servings of fish per week are

recommended.recommended.

� Although most studies in persons with diabetes who have used

omega-3 supplements show beneficial lowering of triglycerides,

an accompanying rise in LDL cholesterol also has been

noted. If supplements are used, the effects on LDL cholesterol

should be monitored.

Vitamins

� No clear evidence has been established for benefits from vitamin or mineral supplements in persons with diabetes (who have no deficiency).

� In selected groups such as the elderly, pregnant or lactating women, strict vegetarians, or those on calorie-restricted diets, a multivitamin supplement may be needed.

� Clinical trial data not only indicate the lack of benefit from antioxidants on glycemic control and progression of complications but also provide evidence of the potential harm of vitamin E, carotene, and other antioxidantsupplements. � Routine supplementation with antioxidants such as vitamins E an d C and

carotene is not advised because of lack of evidence of effectiveness and concern related to long-term safety.

Dietary Supplements

� Alfa-lipoic acid (ALA)

� ALA slows the progression of neuropathy

� Improving the neuropathy symptoms.

� Chromium

٨٨

� Chromium

� Benefit from chromium supplementation has not been clearly demonstrated and therefore is not recommended.

Exercise Guidelines

� Carbohydrate for Insulin or Insulin Secretagogue Users.

� Insulin Guidelines

� For most persons a modest decrease (of approximately 1 to 2 units) in the rapid- or short-acting insulin during the period of units) in the rapid- or short-acting insulin during the period of exercise is a good starting point.

� Heat Intolerance: � When persons with diabetes live and exercise in hot climates, they may experience "heat unawareness" because of their impaired ability to sweat and sense thirst. It is important to suggest adequate hydration techniques to counteract this effect.

Exercise Precautions for Persons with Type 2 Diabetes

� Persons with T2DM may have a lower V02max and therefore need a more gradual training program.

� Rest periods may be needed, but this does not impair the training effect from physical activity.

� Autonomic neuropathy or medications, such as for � Autonomic neuropathy or medications, such as for blood pressure, may not allow for increased heart rate, and individuals must learn to use perceived exertion as a means of determining exercise intensity.

� Blood pressure may also increase more in persons with diabetes than in those who do not have diabetes, and exercise should not be undertaken if systolic blood pressure is greater than 180 to 200 mm Hg

Precautions and Considerations٩١

� Rule out significant cardiovascular diseases or silent ischemia

� Prevent hypoglycemia with self-monitoring of capillary blood glucose (SMCBG) both before and after exercisingafter exercising

� Strenuous exercise not recommended for people with poor metabolic control and significant complications

Types of exercise٩٢

�Walking

�Biking and stationary cycling

�Lap swimming and water aerobics

�Weight lifting�Weight lifting

�At least 3-4 times a week, 30-40 minutes per session, 50 to 70% of maximum oxygen uptake

٩٣

Self-Management Education

� Diabetes management is a team effort.

� Persons with diabetes must be at the center of the team because they have the responsibility for day-to-day management. management.

� The goal is to provide patients with the knowledge, skills, and motivation to incorporate self-management into their daily lifestyles.

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٩٧

Insulin Types٩٨

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Special notes for Preexisting Diabetes and Pregnancy

� MNT goals:

� achieving and maintaining optimal blood glucose control and to provide adequate maternal and fetal nutrition throughout pregnancy, energy intake for appropriate maternal weight gain, and necessary vitamins and minerals.

� Nutrition recommendations are similar to normal pregnant women.

� The need for insulin increases during the second and third trimesters of pregnancy. At 38 to 40 weeks' postconception, insulin needs and levels peak at two to three times prepregnancy levels.

Special notes for Preexisting Diabetes and Pregnancy

� Maintaining consistency of times and amounts of food eaten are essential to avoid hypoglycemia caused by the continuous fetal draw of glucose from the mother.

Smaller meals and more frequent snacks are often � Smaller meals and more frequent snacks are often needed.

� A late-evening snack is often necessary to decrease the likelihood of overnight hypoglycemia and fasting ketosis.

� Records of food intake and blood glucose values are essential for determining whether glycemic goals are being met and for preventing and correcting ketosis.

� Urine or blood ketones during pregnancy may signal starvation ketosis that can be caused by inadequate energy or carbohydrate intake, omission of meals or snacks, or prolonged intervals between meals (e.g., more than 10 hours between the

١٠٢

Special notes for Preexisting Diabetes and Pregnancy

meals (e.g., more than 10 hours between the bedtime snack and breakfast).

� Ketonemia during pregnancy has been associated with reduced IQ scores in children, and women should be instructed to test for ketones periodically before breakfast.

Special notes for patients with GDM

� Carbohydrates should be distributed throughout the day into three small to moderate size meals and two to four snacks.

� All women require a minimum of 175 g of carbohydrates daily.

� An evening snack is usually needed to prevent accelerated ketosis overnight.overnight.

� Carbohydrates are not as well tolerated at breakfast as they are at other meals because of increased levels of cortisol and growth hormones.

� To compensate, the initial food plan may have approximately 30 g of carbohydrate at breakfast.

� To satisfy hunger, protein foods can be added because they do not affect blood glucose levels.

Special notes for patients with GDM

� Although caloric restriction must be viewed with caution, a modest energy restriction to slow weight gain is recommended for overweight or obese women with GDM.

� A slight calorie restriction results in a slowing of maternal weight gain in obese women with GDM without causing maternal or fetal compromise or ketonuria. compromise or ketonuria.

� Energy intake of less than approximately 1700 to 1800 kcall day is not advised. Weight gain during pregnancy for women with GDM should be similar to that of women without diabetes.

Special notes for patients with GDM

� Exercise assists in overcoming peripheral resistance to insulin and in controlling fasting and postprandial hyperglycemia and may be used as an adjunct to nutrition therapy to improve maternal glycemia

� The ideal form of exercise is unknown, but a brisk walk after meals is often recommended.

١٠٥

meals is often recommended.

� Women with GDM (and women with preexisting diabetes) should be encouraged to breastfeed because breastfeeding is associated with a reduced incidence of future T2DM.

� For women with GDM who are overweight or obese or with above-recommended weight gain during pregnancy, weight loss is advised after delivery. Weight loss reduces the risks of recurrent GDM or future development of T2DM

Acute Complications١٠٧

�Metabolic

� Diabetic Ketoacidosis (DKA)

� Hyperosmolar Hyperglycemis Nonketotic Syndrome (HHNS)

� Hypoglycemia

� Infection � Infection

�Quality of Life

Hypoglycemia١٠٨

� Factors Attributing to Hypoglycemia:

� Exercise

� Alcohol Intake

� Other Drugs

� Decreased Liver or Kidney Function� Decreased Liver or Kidney Function

Signs of Hypoglycemia١٠٩

� Glucose level < 60 mg/dL

� Mild Hypoglycemia:� Pallor, Diaphoresis, Tachycardia, Palpitations, Hunger, Paresthesias, Shakiness

� Moderate Hypoglycemia� Moderate Hypoglycemia� Inability to Concentrate, Confusion, Slurred Speech, Irrational or uncontrolled behavior, slowed reaction time, blurred vision, somnolence, extreme fatigue

Signs of Hypoglycemia١١٠

� Severe Hypoglycemia

� Completely automated/disoriented behavior

� Loss of Consciousness

� Inability to arouse from sleep

� seizures� seizures

١١١

Treatment١١٢

� Goal is to normalize the plasma glucose level as quickly as possible

� Mild Hypoglycemia: 3 glucose tablets, ½ cup fruit juice, 2 tablespoon rains, 5 lifesavers candy, ½ to ¾ cup regular soda, 1 cup milk½ to ¾ cup regular soda, 1 cup milk

� Moderate Hypoglycemia: Larger amount of CHO that are rapidly absorbed

� Severe Hypoglycemia: IV glucose or Glucagon (1mg), Glucose gel, Honey, syrup, jelly

Prevention١١٣

� Know the signs and symptoms of hypoglycemia

� Try to eat regular meals

� Carry a source of CHO

� Perform SMCBG regularly � Perform SMCBG regularly

� Use regular insulin 30 minutes before eating

� Schedule exercise appropriately, adjust meal times,

calorie intake, insulin dosing

� Check blood glucose before sleeping

Quality of life١١٤

� Patients with blood glucose values consistently greater than 200 mg/dL will have a reduced quality of life.

� Poor work performance, infections, periodontal diseases, blurred vision, and among elderly, higher diseases, blurred vision, and among elderly, higher incidence of falls

SummarySummarySummarySummary١١٥

�Good nutrition is one of the keys to managing

Type 2 Diabetes

�Nutrition guidelines for Type 2 Diabetes focus on

controlling carbohydrate and fat intake

�Weight management and exercise are also key

�Seek help to set and reach your nutrition and

exercise goals

Thank you ١١٦

Exercise (Sample cases):

� Gender: male

� Age: 65

� Weight: 90

� Height: 172

١١٧

� Height: 172

� HDL: 30

� LDL: 189

� TG: 155

� BP: 140/100

١١٨

اندازه واحد ها و ميزان كربوهيدرات ، پروتيين ، چربي و انرژي � فهرست جانشيني

انرژي چربي پروتيين كربوهيدرات فهرست

شير

90 1 8 12 بي چربي

120 5 8 12 120كم چربي 5 8 12 كم چربي

150 8 8 12 پرچربي

25 - 2 5 سبزي

60 - - 15 ميوه

20 - - 5 قند و شكر

80 1 3 15 نشاسته

انرژي چربي پروتيين كربوهيدرات فهرست

1 �?�*

35 1 7 - بسيار کم چربي

55 3 7 - كم چربي

75 5 7 - 75متوسط 5 7 - متوسط چربي

100 8 7 - پر چربی

35 5 - - چربی