DIET AND LIFE STYLE MODIFICATION AND

OBESITY MANAGEMENT
Introduction
Diabetes mellitus is an epidemic disease worldwide. The global prevalence of
diabetes is projected to reach 439 million or 7.7 % of the world population by
2030. It has become the tsunami of non-communicable chronic disease, with its
alarmingly high prevalence largely driven by the global obesity epidemic. While
an aging population drives much of the increase in diabetes prevalence, a
substantial and potentially preventable proportion of this epidemic is also
directly attributable to the parallel increase in global obesity. The goals of
diabetic care include minimizing long term complications and avoiding
hypoglycaemia. Since, diabetes to a great extent, is a life style disease and has
become one of the major cause of death in people younger than 60 years,
investment in effective diabetes prevention has become absolutely necessary to
battle this global epidemic.

Role of Diet in the Pathogenesis of Diabetes

Along with urbanisation and economic growth, many countries have
experienced dietary changes favouring a rise in caloric consumption and decline
in overall diet quality. Although an unhealthy diet has been regarded as a major
contributor to diabetes development for a long time, only in the past two
decades has the evidence vastly accumulated from both prospective
observational studies and randomised controlled trials (RCTs).
There has been huge urbanisation and environmental transitions including work
pattern changes from heavy labour to sedentary occupations, increased
computerisation and mechanisation, and improved transportation. All these
changes have led to drastic changes in food production, processing, and
distribution of unhealthy foods.
There is a genetic vulnerability for the disease that is complemented by an
unhealthy life style to cause the disease. Fast food restaurants have experienced
exponential global expansion in the past few decades. The increased availability
of fast food has contributed to unhealthy diets with high calorie content and
large portion sizes. Highly refined carbohydrates, sugary beverages, unhealthy
fats are also the net result of the easily available fast food in this mechanical life

when human priorities have changed. Local fresh food is completely ignored
because of the time consumed in preparing it and highly processed foods are
preferred that results in overeating resulting in obesity.
Furthermore, an important factor in nutrition transition is the increased
refinement of grain products. Milling and processing of whole-grains to produce
refined grains such as polished white rice and refined wheat flour reduces the
nutritional content of grains, including their fibre, micronutrients and
phytochemicals.
Thus, sedentary life-style, wrong eating habits with preferential consumption of
refined carbohydrates, sugars and fats combined with mental and emotional
stress strongly contributes to the development of the deadly disease of diabetes.

General Management Issues in Diabetes

Most of the guidelines highly recommend Life style management as the first
necessary step in the management of diabetes, which alone increases the risk of
developing many chronic diseases like cardiovascular diseases, chronic kidney
disease, osteoporosis, and certain cancers. Diabetes being a metabolic disease,
the bodys ability to metabolize food in general and especially carbohydrates is
greatly compromised. It is of utmost importance that if the food cannot be
metabolized well by a diabetic patient then the food in terms of quantity and
quality is altered to be managed by the compromised system. Life style
modification is aimed at reducing energy intake and increasing physical activity
in all patients of Type 2 diabetes especially targeting the overweight and obese
patients.
In general population as well as pre-diabetics, the effectiveness of intensive life
style interventions to prevent, or at least delay, the onset of Type 2 diabetes has
been demonstrated. (1)
Exercise comprises a key component in the life style management of diabetes.
It reduces insulin resistance and and improves the functioning of every organ
system of the body. Thus, exercise deserves an equal emphasis as the dietary
manipulation in the disease management. Such a program must be tailored
according to the needs of an individual keeping in mind the degree of fitness
and associated co-morbid conditions along with overall health status. However,
patients must be educated regarding the potential risk of hypoglycaemia and
measures to be taken at that moment.

Two types of physical activity are most important for managing diabetes:
aerobic exercise and strength training.
Aerobic Exercises means anything that involves continuous and repeated
contractions of skeletal muscles. It charges the metabolism like
nothing else can compare. It helps increasing the insulin sensitivity
thus uses insulin better. It makes ones heart and bones strong, relieves
stress, improves blood circulation, and reduces the risk for heart
disease
by
lowering blood
glucose and blood
pressure and
improving cholesterol levels.
One should aim for 30 minutes of moderate-to-vigorous intensity aerobic
exercise at least 5 days a week or a total of 150 minutes per week. It is
recommended to spread the activity over at least 3 days during the week and it
is emphasized to not to go more than 2 days in a row without exercising.
Moderate intensity means that while working hard enough one can talk, but not
sing, during the activity. Vigorous intensity means one cannot say more than a
few words without pausing for a breath during the activity.
For the people with busy schedule that doesn't allow them to exercise for a 30minute period during the day, it is suggested to break it up into bouts of 10
minutes or more. Research has shown that the health benefits are similar when
this method is adopted.
Below are some examples of aerobic activities:

Brisk walking (outside or inside on a treadmill)

Bicycling/Stationary cycling indoors

Dancing

Low-impact aerobics

Swimming or water aerobics

Playing tennis

Stair climbing

Jogging/Running

Hiking

Rowing

Ice-skating or roller-skating

Cross-country skiing

Moderate-to-heavy gardening

Isometric or pressure exercises or Strength Training, also called resistance

training includes the exercises that cause intense but not repeated
contraction of skeletal muscles. Such exercises improve the bulk and
tone of skeletal muscles. Larger muscle mass and greater tone of
muscles helps in their metabolic enhancement. It is
recommended to do some type of strength training at least 2
times per week in addition to aerobic activity. Pressure exercises tend
to increase blood pressure and therefore, are not recommended for
patients with heart disease. It is always encouraged to start the
exercises at low intensity and for smaller durations and to gradually
increase time and pressure upto the final desired levels.
Below are examples of strength training activities:

Weight machines or free weights at the gym

Using resistance bands
Exercises that use your own body weight to work your muscles
(examples are pushups, sit ups, squats, lunges, wall-sits and planks)

Diet and Exercise rather form the key foundation of a comprehensive diabetes
management program. If life style is taken care of, it not only provides overall
feeling of well being but also ends up with requirement of minimum medicines
and delay of complications.
Although it is true that often difficult for patients to comply with the life style
management advice over an entire life time, yet it is of great importance to
strongly emphasize and re-emphasize the life style management methods on
every visit to the doctor.
Comprehensive management is mandatory in the treatment of diabetes and it
not only considers lowering the blood glucose level but also should focus on the
correction of any associated cardiovascular risk factors such as hypertension,
smoking, dyslipidaemia and obesity.

Self monitoring of blood glucose (SMBG) constitutes an important parameter

in achieving the good control of blood sugar that remains the key factor in the
management of diabetes. Self monitoring of blood glucose improves the quality
and safety of therapy.
Target setting should be tailored according to the individuals needs and are
continuously modified from time to time for best outcomes.
With rapid changes in our understanding in the aetio-pathogenesis of Type 2
diabetes, there has been a paradigm shift in the treatment modalities. With the
advanced approach of Octet Concept, diabetes management has also moved
from being Gluco-centric to Disease-centric. There has been a wide variety
of new therapeutic options available to treat Type 2 diabetes and each of these
agents broadly show s similar efficacy as mono-therapy with hardly any
significant glucose lowering potency. These agents are primarily different in
their adverse event profile that either could be related to their specific
mechanism of action and/or potential off-target effects. Some of these side
effects include hypoglycaemia or weight gain and these adverse effects
actually promote the cardiovascular risk in these patients and may therefore,
negate the potential CV benefits of some of the glucose lowering agents.
There is a general agreement and almost all recent guidelines recommend
Metformin as the first line drug but uncertainty remains regarding the choice
of the second line drug when metformin no longer remains effective. Metformin
montherapy in Type 2 diabetic patients, not adequately controlled by diet is
reported to reduce fasting plasma glucose by 20%and glucosylated haemoglobin
by 2%. It has been shown to control hyperglycemia as effectively as
sulfonylureas, and is equally effective in both lean and obese diabetics.
Metformin has revealed a number of unique pharmacological actions and
potential clinical advantages when compared with sulfonylureas.
Advatages of Metformin over sulfonylureas include:
1. Lack of weight gain
2. No increase in plasma insulin or hyperinsulinemia, thus no resultant
hypogycemia
3. Persistent efficacy for over 2-5 years when used alone or in combination
therapy
4. Favourable changes in lipid profile in the form of decreased triglycerides
and modest LDL reduction of about % and HDL elevation

5. Reduction of blood pressure

6. Ultimately resulting in the avoidance or delay in the need for insulin
injections
There is no consensus that when metformin fails, what to add as the next agent
as to achieve the glycemic control. Combination of sulfonylureas and
metformin has a synergistic effect, since both agents act to improve glucose
tolerance by different mechanism of action. This complementary effect has been
observed in multiple studies and is well accepted regimen in the management of
diabetes. Although hypoglycaemia represents an important clinical problem in
terms of quality of life, risk of falls and coma especially in elderly but the risk is
substantially lower with newer generation sulfonylureas. Furthermore,
sulfonylureas are the oldest of the oral hypoglycaemic agents that have stood
the test of time in cementing their place in the management of Type 2 diabetes.
They have historically been analysed as a drug class, despite the fact that there
are vast differences in the pharmacological properties of individual
sulfonylureas w.r.t risk of hypoglycaemia, sulfonyl receptor (SUR) subtype
specificity and affinity and the ability to abolish ischaemic preconditioning.
Newer generation sulfonylureas like gliclazide and glimepiride that provide
high efficacy without compromising safety have virtually replaced the older and
obsolete glibenclamide because of associated high risk of hypoglycaemia
especially in elderly. Thus, newer generation sulfonylureas with their evidence,
experience and cost-effectiveness continues to be the preferred second line
therapy after metformin.
Fixed drug combinations offer a unique advantage of not only providing a
synergistic mode of action but also, they reduce the pill burden, which is a very
important factor in improving the compliance of patients with better adherence
to the treatment regimen.

Nutrient composition of diet in Diabetes

Life style intervention with calorie restriction and exercise to promote weight
loss, as shown in the Diabetic Prevention Program (2) significantly reduces
conversion of diabetes in high risk patients with impaired glucose tolerance by
58%
Proper nutrition requires the proper ingestion and equally important, the
absorption of vitamins, minerals and food energy in the form of carbohydrates
proteins and fats . Dietary habit and choice plays a significant role in health .

The food consumed by a person changes the blood sugar level in different ways.
So it is important to learn how to make healthy food choices that helps to
control the blood sugar level. To control the blood sugar level it is important to
eat healthy food at the right time and in the right amount. It is beneficial to eat
smaller, more frequent meals, rather than two or three big meals most people
consume daily . The recommendations are appropriate to the evidence available.
Although data on individual dietary items remains inconclusive, the analysis of
dietary patterns is compelling. Studies consistently demonstrate that diets rich in
fruit and vegetables, whole grains, legumes and low in red and processed meat,
SFA, and refined grains protect from type 2 diabetes development . Individuals
who consume a healthy diet are also often more active; further research into the
role of physical activity for the prevention of type 2 diabetes and its relationship
with dietary habits should be encouraged (3).
Carbohydrate
Regarding quantity and quality of carbohydrates:
Perspective observational evidence suggests that the relative carbohydrate
proportion of the diet does not appreciably affect the risk of diabetes(4) .
However, a diet rich in fibre, especially cereal fibre, might reduce the risk of
diabetes. Findings from a meta analysis of prospective cohort studies showed an
inverse association between fibre from cereal products and risk of type 2
diabetes.Fibre from fruits had a weaker inverse association than did cereal fibre.
Carbohydrate quality can be measured by evaluation of the glycemic response
to carbohydrate rich foods, such as the Glycemic index(GI) and Glycemic
load(GL, a product of GI and the amount of carbohydartes of a food).In meta
analysis of prospective studies, low GI and low GL diets were associated with
low risk of diabetes than were the diets with a higher GI and GL, independent of
the amount of cereal fibre in the diet.
Carbohydrate is the nutrition term used for starch, sugar and fiber. Carbohydrate
plays a very important role in the control of type 2diabetes
High glycemic index (GI) foods break down quickly whereas low GI foods
break down slowly. With low GI foods we feel full for a longer duration and our
bodys insulin has more time to perform its job and remove glucose from the
blood. One of the first dietary rules for all patients with diabetes is to avoid all
sugar and foods containing sugar, such as pastry,candy and soft drinks .

Individual foods and food groups:

Prospective studies have provided the evidence that intake of several individual
food items or food groups might play a part in prevention of diabetes. (5)
Whole grain intake has been consistently associated with a lower risk of
diabetes even after adjustment of BMI. (5) Conversely, greater intake of white
rice, a processed grain, was associated with an increased risk of diabetes,
especially in Asian population where white rice is a staple food and main source
of calories. Frequent consumption of red meat especially processed red meat
such as bacon, sausages, and hot-dogs has been found to be associated with high
risk of diabetes.
Beverages
Studies have shown that greater intake of sugar sweetened beverages has been
associated with the high risk of diabetes. This association remains significant
even after adjusting for BMI, which suggests the deleterious effects of sugar
sweetened beverages are not entirely mediated by body weight. Substitution of
water, coffee or tea for sugar sweetened beverages was associated with the
lower risk of diabetes (6).
Protein
The current nutrition recommendation for adults with type 2 DM do not indicate
protein restriction. For people on energy reduced diets for weight loss
,however,an incresed protien intake as percentage of calories is important
because use of a fixed percentage of total calories to estimate a protien
requirement might result in inadequate protien intake and lean muscle mass(7).
As per the Position Statement of ADA( 2013), following are the
recommendations regarding the protein intake in patients with type 2 diabetes
1.For people with diabetes and no evidence of diabetic kidney disease, evidence
is inconclusive to recommend an ideal amount of protein intake for optimizing
glycemic control or improving one or more CVD risk measures; therefore, goals
should be individualized.
2.For people with diabetes and diabetic kidney disease (either micro- or
macroalbuminuria), reducing the amount of dietary protein below the usual

intake is not recommended because it does not alter glycemic measures,

cardiovascular risk measures, or the course of glomerular filtration rate (GFR)
decline.
3.In individuals with type 2 diabetes, ingested protein appears to increase
insulin response without increasing plasma glucose concentrations. Therefore,
carbohydrate sources high in protein should not be used to treat or prevent
hypoglycemia.
Fat
As per the Position Statement of ADA( 2013), following are the
recommendations regarding the fat intake in patients with type 2 diabetes
1.Evidence is inconclusive for an ideal amount of total fat intake for people
with diabetes; therefore goals should be individualized .
2.Evidence suggests that fat quality is far more important than the total fat
quantity to support metabolic goals.
Currently, insufficient data exist to determine a defined level of total energy
intake from fat at which risk of inadequacy or prevention of chronic disease
occurs, so there is no adequate intake or recommended daily allowance for total
fat(8).
Although , the specific recommendations for distribution of fat composition
vary, a reduction in the intake of saturated fat and trans fat from industrial
hydrogenation to reduce CV disease risk, is recommended.

REFERENCES
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RT, et al. Pharmacological and lifestyle interventions to prevent or
delay Type 2 diabetes in people with impaired glucose tolerance:
systematic review and meta-analysis. BMJ. 2007; 334:229-37.

3. Patrice C, Kamlesh K, Melanie JD. Dietary recommendations for the

prevention of Type 2 Diabetes : whar are they based on ? J Nutr Metab
2012, 84(7) :202

4.Hauner H, Bechthold A, Boeing H, et al , Evidence-Based Guideline of

the German Nutrition Society:Carbohydrate Intake and Prevention of
NutritionRelated Diseases. Ann Nutr Metab 2012;60(suppl 1):1-58
5. Aune D, Norat T, Romandstud P, Vatten LJ. Whole grain and refined
grain consumption and the risk of type 2 diabetes: a systemic review and
dose response meta-analysis of cohort studies. Eur J Epidemiol 2013;
28:845-58.
6. Pan A, Malik VS, Schulze MB, Manson JE, Willett WC: Plain water
intake and risk of type 2 diabetes in young and middle aged women. Am
J Clin Nutr 2012; 95:1454-60

7.Canadian diabetes association clinical practice guidelines expert

committe. Clinical Practice Guidelines:nutrtion therapy.Can J Diabetes
2013;37:S45-55
8. Institute of Medicine. Dietary Reference Intakes for Energy,
Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and
Amino Acids. Washington, DC, National Academies Press, 2002