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!”