Unit 5
Diploma in Diabetes and Children and Young
People – Level
2
Module 5: Dietary considerations
1. Diet
2. Eating diabetic foods
3. Sweets and treats
4. Experimenting with alcohol
5. Understanding carbohydrates
6. Fats
7. Fizzy drinks and fruit juices
8. The importance of water
9. Eating disorders
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Module 5 Dietary considerations
Introduction
Diet plays a very important part in the control of diabetes. In this module the learner
will discover why good nutrition is so significant to health in general but more so in
diabetes. It explains the effects diets have on the condition and how to eat to control
blood glucose levels.
Learning outcomes – the learner will:
• Understand the importance of good nutrition
• Obtain a good comprehension of the nutritional needs of sufferers of diabetes
• Have the ability to encourage service users to eat correctly to fight off the risks
of long term heart problems and high cholesterol
• Be able to give diabetic sufferers lessons on what foods to eat to help to keep
their blood glucose levels steady
• Have the knowledge of what to give to a person who has low blood sugar levels
• Have an understanding of the foods that can cause harm to the service user’s
well-being
• Understand the link between type 1 diabetes and eating disorders
Diet
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Nutrition is not just about a weight loss diet or having to eat foods that you don’t like
just to lose weight. Good nutrition equates to good health. Excellent nutrition is
paramount when someone has diabetes. There are too many diabetics who do not
take their nutritional needs and requirements seriously enough. It is important that a
diabetic adheres to a few rules to keep themselves healthy, these are:
• Knowing how to carb count accurately and taking insulin to match the
carbohydrate dose. Carb counting and matching insulin requirements is the key factor
for managing type 1 effectively
• Consuming huge quantities of red meat regularly increases the bad cholesterol
in the blood, so eating fish and chicken or turkey is a better option
• Putting table salt directly onto the foods that have already been cooked in salt
can increase the blood pressure. Salt should never be added to the plate
• Drinking copious amounts of alcohol will lead to severe health complications in
both diabetics and non-diabetics
• Smoking too must be avoided if a diabetic wants to live a healthy, long life.
Smoking increases the risk of long term diabetes complications.
This doesn’t mean that as a diabetic the child can never have anything containing
sugar again, or ever allow any amount of alcohol to pass their lips. We have already
seen how people with type 1 can enjoy the foods and drinks they did prior to diagnosis,
as long as they carb count them and take insulin.
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Eating diabetic foods
'Diabetic foods' are much more widely available now than they used to be. These
foods don't contain any added sugar or are sugar free. People assume this means
that a diabetic service user can eat as much as they like of this product without having
any adverse effects from it.
Instead of sugar, manufacturers use another product to sweeten their foods, this is
called Polyols. Polyols are sweeteners that include xylitol, maltitol, sorbitol, mannitol
and isomalt. These sweeteners are sometimes used in cakes, biscuits and
confectionery and sold as a diabetic food stuff. The problem with this is that foods
made with these products are often high in saturated fats and in calories, therefore
they shouldn’t be eaten freely and limitation should be adhered to.
'Diabetic foods' are designed for the type 2 diabetic market are often much more
expensive than other foods. If bought often this could quickly amount to a large
amount of money.
Please note: Type 1 diabetics are advised NOT to eat diabetic foods.
Large consumptions of foods containing Polyols can cause gastric problems, such as
flatulence or diarrhoea and they also have a laxative effect. People who take insulin
and who count carbohydrates will still need insulin with diabetic foods because many
of them still contain carbs. Doctors and dieticians do not recommend use of diabetic
foods and they see them as a marketing gimmick.
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Sweets and treats
Children especially love treats in the form of sweets, chocolate, biscuits and cakes.
Being diabetic, as touched upon previously, these children CAN enjoy these treats
just as much as their non-diabetic peers, but they need to make sure any treats they
have are carb counted and that they use insulin appropriately to maintain healthy
blood sugar levels. It is not advisable for anyone to eat too many treats and this is
even more important for someone with diabetes.
It is thought by some people who care for a diabetic child that once they are diagnosed
they will never be able to eat anything containing sugar again. This isn't true, but if
they are eating sugar on a daily basis and lots of it, then they will have problems.
Sugar can be eaten in the form of a couple of squares of chocolate, a few sweets or
a piece of rich fruit or chocolate cake, but only occasionally and as part of a sensible
diet.
Eating often
It is vital that children and young people with type 1 diabetes eat regularly and don’t
skip meals. Teenagers may think that by skipping a meal they will lose weight,
however, this isn’t the case. When meals are missed the body prepares itself to go
into starvation mode and holds onto the fat cells for fuel. As this happens the body is
not losing weight. Going too long without food can cause the blood glucose levels to
drop or leave the person at risk of hypoglycaemia, making the service user feel
lethargic, irritable, tired and unwell.
Large consumption of fruit and vegetables
Fruit and vegetables are packed with vitamins essential for a healthy body. They are
known to reduce heart disease and some cancers. Fruits and vegetables should be a
large part of the diet. However, with diabetes there is a note of caution.
Grapes contain a lot of natural sugars and should be spaced out throughout the day.
There is nothing wrong with a diabetic service user eating grapes
but better if they don’t eat too many at one time. The same applies
to all fruits. Eating a large orange, an apple, banana, handful of
grapes, pear and peaches all at once will cause the sugar levels to
rise. It is better to have the fruits throughout the day such as a
banana with breakfast, the apple for a snack, grapes with lunch, a
peach later for a snack and so on. Try not to put a lot of fruit in the
child's lunch box as children will not think about only eating a small
amount at once, if that child is hungry they will eat it.
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Choose water and calorie-free "diet" drinks instead of regular sugar sweetened
drinks
Some soft drinks contain a huge amount of sugar, therefore it is a better option to
have low sugar varieties, unless insulin is taken with the drink. Better still, drink lots
of water.
Watch portion sizes
Portion sizes can be misleading. It is important to give an insulin dose that matches
the portion size, if necessary, weigh the food to determine the portion size. As time
goes on, you will get better at estimating carbs based on portion size.
Experimenting with alcohol
When a young person gets into their teenage years it is natural for them to want to
taste alcohol and experiment with it with their friends. This unfortunately does have
hidden dangers for sufferers of diabetes.
Alcohol lowers blood glucose levels so that the young person could easily go into a
hypo because of the insulin they take. Alcohol stops the body releasing glucose into
the bloodstream. When a teenager starts to drink they will be unaware of the
sensations that they are experiencing thinking that this is just part of being drunk. Peer
pressure can influence the teenager to try different alcohols. This is fine in moderation
and never on an empty stomach. But if this pressure from friends increases it can lead
to a serious problem.
Seeing their friends laughing and seemingly having a good time is what every
teenager wants. Alcohol consumption is not a good idea if too much is consumed,
either diabetic or not this can cause a serious problem.
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Consider this scenario:
An 18-year-old male, Tom is going out with his friends to celebrate his 18th birthday.
The group of friends begin at Tom’s house where they drink a couple of cans of lager
and plan their night. They all then go to the nearest pub where they meet up with other
friends. As it’s his birthday, people are buying Tom drinks all night. He tries to refuse
but they are still being bought for him.
As he was eager to get out with his friends Tom didn't have time to eat any dinner
before he left home. As the night progresses Tom is feeling a little light headed and
assumes that it is the alcohol that he is drinking. As he is having such a good time he
ignores the sensations he is experiencing and continues to join his friends in another
round of drinks. Everyone is feeling happy and laughing and the slurring of words is
apparent from most of the revelers. Tom is also slurring his words, but he is staggering
too and feeling incredibly shaky.
Tom tries to laugh with his friends but he doesn’t like this feeling he is having
especially now as he is sweating and becoming confused. Tom tries to have another
drink to make himself feel better. He feels nauseous by now and has difficulty in
speaking. Tom is experiencing a hypo.
If Tom had told his friends that he was type 1 diabetic and wasn't able to drink the
quantities that they are, things may have been different. Also Tom didn’t have his
dinner before he left home, so his blood sugar level would be dropping anyway. This
is a lethal combination for a diabetes sufferer.
Type 1 diabetics need to eat especially if they have alcohol in their system. Eating a
sandwich before he went out may have helped to prevent Tom from going into a hypo.
It is also important to eat something whilst drinking, such as a packet of crisps and
then afterwards before he goes to bed. Going to bed after drinking alcohol and not
eating can also cause the young person to go into a hypo. A snack will suffice to
prevent this from happening.
Snacks don't have to be a piece of fruit as this can be difficult to carry around or to
eat. Handy packets of dried fruit can be eaten. Bread sticks are an easy option as are
yogurts and fromage frais. Eating the odd biscuit in times when a snack is needed is
not a problem, but eating the whole packet is. If other snacks
are not available, the service user can have a glass of milk.
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Understanding carbohydrates
What foods are carbohydrates? Usually when this question is asked many people will
say bread and pasta. True, these are carbohydrates but there are many other foods
that fit into this category. Then we have the different types of carbohydrates, the
complex carbs and the simple carbs, now it starts to become more complicated and
very confusing. Carbohydrates are a fantastic source of energy that the body needs.
In fact, every cell in the body uses carbohydrates for energy. They can easily be
converted into glucose which is a good thing, however, too much carbohydrate can
affect blood sugar levels.
Complex carbs release energy into the body slowly and over a longer period of time,
whilst simple carbs release the energy much quicker and over a short period of time.
Complex carbs cause the person to feel full for longer, whilst simple carbs cause the
person to feel full for a shorter amount of time and they will feel hungry again soon
after eating them.
Example: breakfast
2 slices of white toast contains 30g of carbs, this is a simple carb and will take around
1 ½ to 2 hours for the body to use the energy; a surge of energy will be released quite
suddenly, peak and then wear off, then the person will feel hungry again. As the
energy releases, the blood sugar also rises, so this toast will cause a sudden peak
and then drop in blood sugar.
A bowl of porridge also contains 30g of carbs, but this is a complex carb, the energy
from porridge releases into the body slowly and does not peak, the body may release
the energy from this porridge over 4 hours, causing more stable blood sugars and
keeping hunger at bay for longer. This type of carb will not cause the blood sugar to
peak and drop, it will keep blood sugars at a steady rate as the energy is steadily
released.
It is clear to see from this example that both breakfast choices contain the same
amount of carbohydrates, but their action on the body are very different.
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The complex carbs
Here is a list of the complex carbohydrates:
• Barley
• Brown Rice
• Chickpeas
• Lentils
• Muesli,
• Nuts
• Oats
• Whole Barley
• Oat Bran Cereal
• Oat Bran Bread
• Wild Rice
• Multi Grain Bread
• Buckwheat
• Soya Beans.
Vegetables: Spinach, turnip greens, potatoes, parsnips, lettuce, watercress,
courgettes, sweet corn, yams, asparagus, artichokes, cabbage, celery, carrots,
cucumbers, radishes, cauliflower, aubergine, kidney beans, Brussels sprouts, onions,
broccoli and okra.
Fruits: Grapefruits, bananas, apples, prunes, dried apricots, pears, plums,
strawberries and oranges.
Whole grains: Wholegrain cereals, wholemeal breads, wholemeal cereals,
wholemeal flour and wholemeal pasta. These are high fibre foods that improve the
digestion. Complex carbs take longer to digest and are normally crammed full of good
nutrients such as fibre, vitamins and minerals. They also keep you feeling fuller for
longer and provide a sustained release of energy, that’s why people on diets fill up on
the complex carbs such as vegetables and wholegrain foods.
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Simple carbohydrates
Simple carbohydrates are also known as sugars. They are digested much quicker
than complex carbs and also exist in either a natural or refined form.
Refined sugars are found in:
• Biscuits
• Chocolate
• Cakes
• Pastry
• Pizzas
• Table sugar
• Honey
• Jams
• Prepared sauces
• Soft drinks
• Fruit juice
• Bread made with white flour
• Pasta made with white flour
• All baked foods that are made with white flour
• Most breakfast cereals
• White rice
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Understanding fibre
Again, like carbohydrates, fibre is another one of those subjects that gets people
confused. What’s the difference between soluble fibre and insoluble fibre? Simply put,
fibre is the part of the carbohydrate that isn’t digestible.
Insoluble fibre
This is most probably recognised by the name roughage. This fibre cannot dissolve
in water and is what the body cannot digest. It moves its way through the intestines
almost intact. It’s this fibre that makes the stools softer and easier to pass, preventing
constipation. The best sources of insoluble fibre are nuts and seeds, dark green leafy
vegetables, wheat bran, skins of fruits and skins of vegetables.
Soluble fibre
This fibre can dissolve in water and helps you to feel full after eating. It is known to
help to lower cholesterol and blood glucose. Good sources of soluble fibre are oats
and oat bran, nuts, barley, flaxseeds, oranges and apples. Eating too much fibre will
produce excess wind and even diarrhoea so it is important to introduce fibre slowly if
your service user isn’t used to it.
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Fats
What are fats? Well basically, fat makes you fat! If you eat fat it will cause you to gain
weight and clog up the arteries causing heart attacks. All fats are bad fats, aren’t they?
They all increase the waistline and make us go up a dress size or two. Well actually
no! There are good fats and bad fats. The good fats help to improve health and
obviously bad fats cause ill health. Fats are essential to the body and do provide us
with energy. They also help the body to absorb certain vitamins.
The good fats and the bad fats The good fats
• Omega 3 oils
• Monounsaturated fats
• Polyunsaturated fats
EFAs are essential fatty acids and have to be obtained by diet as the body doesn’t
make them. EFAs support the nervous system and the cardiovascular system.
They build cell membranes and help to regulate the blood pressure, blood clotting and
fertility. They stimulate hair growth, maintain bone growth and regulate the
metabolism. Omega 3 and oils are the important essential fatty acids and are found
in oily fish, but is also found in nuts and seeds, leafy green vegetables, eggs and
walnuts.
The bad fats
• Saturated fats
• Hydrogenated fats
• Trans fats
These fats are the ones that raise the cholesterol level and block the arteries. These
fats are found in foods such as pies, sausages, margarines, cakes, biscuits, lard and
suet. Saturated fats are usually solid at room temperature. Butter, hard cheese and
lard are three of the fats that are added to many foods. It is also the white fat that you
can see on red meat. Hydrogenated fats are solid or semi solid at room temperature.
Hydrogenation is a process where liquid fats are turned into solid fats. You will find
hydrogenated fats in foods such as biscuits, cakes, margarines and processed foods.
When buying food products, it is important that you read the labels.
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Proteins
The body needs a certain amount of protein. It uses protein for growth, maintenance
and repair of all cells.
Be aware that some proteins are higher in saturated fats than others. This is
particularly important when watching the cholesterol level in the blood. Animal sources
of protein contain a lot of hidden fats, some more than others. Proteins that are very
lean should be chosen over ones that are high in fat. White meats such as chicken
and turkey are a much better option, but they must have all the skin removed. Fish is
a good low fat source of protein, such as cod and plaice, tuna and sardines. However,
if fried you are adding all the fat to it so it must be grilled, poached or steamed. Cottage
cheese is another low fat option of protein, as are soya products and vegetable
proteins. High fat meats include beef, pork and lamb, these meats should be eaten
sparingly but as part of a low fat diet eating red meat will not cause too much harm,
as long as it is only occasionally. It is best to avoid certain types of protein all together.
These are the foods that have added fat in them such as sausages, burgers, corn
beef, haslets and luncheon meats.
Fizzy drinks and fruit juices
Kids love fizzy drinks, however in each can of cola there is a staggering 10 teaspoons
of sugar. This is a lot of sugar for anyone to consume. If the child wants a fizzy drink
it is always better to offer them a sugar free version, however, this should only be
given in moderation as they contain a lot of aspartame. People suffering from diabetes
can drink full sugar fizzy drinks and fruit juices but this must again be carb counted
and the matching dose of insulin given. Natural fruit juices contain a lot of natural
sugars, in fact, some have more than coca cola. It is worth noting that drinks with a
high sugar content can be very useful in quickly raising blood sugars if they suffer
from a hypo.
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Eating Disorders and Diabetes
ED–DMT1 (Eating Disorders in Diabetes Mellitus Type 1) is the general medical term
used to refer to various eating problems that can co-occur with type 1 diabetes.
There are many reasons why a person with T1 is more likely to develop an eating
disorder, in comparison to their non-diabetic peers:
People with Type 1 Diabetes are twice as likely to develop anorexia or bulimia, or a
special eating disorder called diabulimia, in comparison to their non-diabetic peers:
• Fear of hypoglycaemia – hypo’s can be distressing and can lead to loss of
consciousness. Instead, the person might prefer to omit or severely reduce their
insulin and prefer to have high bloods.
• When hypo, the body sends signals to the brain to consume sugar as quickly
as possible, this results in binge eating commonly associated with bulimia.
• Diabetics may not like testing their blood and injecting insulin, they may
associate food with pain; this could promote anorexic behaviours and the person
might simply avoid eating so they do not have to test their blood and inject.
• All adolescents crave control and independence, type 1 requires great
understanding of the action of both food and insulin on the body, therefore, they can
use this knowledge to their advantage, manipulating knowledge in order to help them
meet their weight loss goals. No or little insulin in the body will mean the person can
eat as much food as they like and lose a considerable amount of weight.
• Easily controlling their body weight gives them a feeling of control, this is in
contrast to controlling their diabetes, which is incredibly hard and often out of control,
no matter how much effort they put into doing so.
• During teenage years, diabetics are expected to start taking responsibility
themselves for their own health, so this is a time when parents, schools and carers
are less involved, so it is easier for the person to omit their insulin and this go un-
noticed.
• The meticulous focus on foods and carb counting in type 1 diabetes can
encourage a thinking mind-set that mimics eating disorders.
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A charity called Diabetics With Eating Disorders (DWED) state that 40% of females
have admitted to missing insulin doses in order to lose weight. In addition, they state
that anyone with Type 1 Diabetes is twice as likely to have a clinically diagnosed
eating disorder. Let’s have a look at some of the different eating disorders people with
type 1 may develop.
Anorexia
Anorexia is a mental health disorder where the person wants to keep their body weight
as low as possible, this is usually achieved any or a combination of the following:
• Avoiding or severely restricting food
• Inducing sickness
• Excessive exercising.
A person with anorexia may have a desire to be thin, a fear of being fat and could
have a distorted body image. Signs that someone may have anorexia include:
• missing or avoiding meals,
• going to the toilet before the end of the meal (so they can be sick),
• Taking laxatives or water tablets to help food & drink leave the body,
• Obsessively weighing themselves
• Dry skin, brittle nails, hair loss and in females, menstruation may stop.
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Bulimia
Bulimia has some similarities to anorexia in that the person wants to look thin and
have a low body weight, but bulimics achieve this by binge eating and then either
being sick or using laxatives to eliminate the calories from their body. A body in a
hypoglycaemic state craves sugar in order to raise the blood sugar, therefore a
diabetic who is hypo will binge eat, in fact, they will need to consume pure sugar in
order to stay alive. All people with Bulimia will binge eat and then feel guilty about
eating and they may induce vomiting or take laxatives, this process then becomes
addictive. Type 1 diabetics do not have to be sick or take laxatives after binge eating
as they will urinate all the calories from food back out.
Diabulimia
Diabulimia is a condition in which a person with type 1 diabetes purposely does not
take or severely restricts their insulin. This causes rapid and excessive weight loss
without needing to control the diet or exercise, but it is also life threatening. When the
body has a lack of insulin, it cannot use glucose or energy and the calories from food
will be flushed out via the kidneys. Instead of using glucose as energy, the body will
burn its own fat, muscle or even tissue from major organs. The result is that the person
can eat as much of whatever foods they want and lose a lot of weight, this is because
they urinate the calories out. This process results in the body making a dangerous
acid called ketones, in turn ketones can lead to DKA, coma and death.
Type 1 diabetics can omit or severely reduce their insulin in order to lose weight fast
and with no effort. The Joselin Diabetes Centre estimates that 40% of females with
type 1 omit insulin on a regular basis in order to control their weight. The weight loss
is very rapid, it is possible that the person will notice a significant difference in their
weight within 24 hours and could lose several stone over a couple of weeks. An
anonymous woman is quoted in a New York Times article describing her diabulimia:
“(after eating bags of crisps, candy and tubs of ice cream) I stepped on the scales
next day and had shed pounds. I knew I was playing with fire, but I didn’t think about
the consequences, just the weight. I got used to my blood sugars running high all the
time. I would get so nauseus I would throw up”
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Diabulimia is a serious and complex condition, in the short term it can lead to DKA,
coma and death. If the person survives this, the longer term consequences include
limb amputation, neuropathy, heart and kidney problems, blindness and death.
Diabulimia is widely accepted within the diabetes community, but it is not officially a
recognizable condition by the National Institute for Clinical Excellence (NICE) or World
Health Organisation(WHO). Instead, any diabetic with an eating disorder will be
diagnosed with ED-DMT1, which can cause problems with treatment. Individuals with
Diabulimia can get told that the condition does not exist and they are simply just non-
compliant with their treatment. Equally, diabetes specialists are not specialists in
eating disorders and mental health specialists do not understand the complexities of
diabetes. Psychiatrists may section someone with diabulimia, but also fail to
understand that insulin is not a psychiatric drug and therefore treatment cannot be
forced. Dieticians can understand diabulimia, but they are not therapists so cannot
provide the specialist help that is needed in order to make people who suffer from it
feel better. Individuals with diabulimia are in desperate need of help for this serious
and life threatening condition, but help is often not there.
Gemma, quoted on the DWED website says: “The first few weeks were hell . . .
I was so short of breath, going to the toilet every two minutes, a mouth like the Sahara
Desert, pain throughout my whole body that brought me to tears. But the main thing,
I had lost weight!!Over the next 6 years I was in and out of hospital, never for poor
diabetic control though, I always knew how to hide that, how to inject just enough units
to bring me back from the point of no return so that nobody would find out!”
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