**11. Nutrition recommendations for controlling diabetes complications**

If there was a family history of hypercholesterolemia (total cholesterol >240 mg/dl) or a fam‐ ily cardiovascular event before age of 55 years, or if family history was unknown, a fasting lipid profile should be performed on children >2 years of age soon after diagnosis (after glu‐ cose control has been established). If family history is not of concern, then the first lipid screening should be considered at puberty (≥10 years). All children diagnosed with diabetes at or after puberty should have a fasting lipid profile performed soon after diagnosis (after glucose control has been established

Initial therapy should consist of optimization of glucose control and MNT using a Step 2 AHA diet (American Heart Association, 2010 Dietary Guidelines) aimed at a decrease in the amount of saturated fat in the diet. People diagnosed with type 1 diabetes in childhood have a high risk of early subclinical (Krantz JS et al, 2004, Järvisalo MJ et al, 2004, Haller MJ., 2004), and clinical (Orchard TJ., et al. 2001) CVD. Although intervention data are lacking, the AHA categorizes children with type 1 diabetes in the highest cardiovascular risk group and recommends both lifestyle and pharmacologic treatment for those with elevated LDL cho‐ lesterol levels (Kavey RE et al, 2006; McCrindle BW et al, 2007). Initial therapy should be with a Step 2 AHA diet, which restricts saturated fat to 7% of total calories and restricts diet‐ ary cholesterol to 200 mg/day. Data from randomized clinical trials in children as young as 7 months of age indicate that this diet is safe and does not interfere with normal growth and development

physical exercise improves insulin resistance and reduction of triglyceride levels and in‐ creases total HDL and HDL2 concentration; it also helps in lowering blood pressure. It re‐ duces mortality in type I diabetes and may reduce HbA1c up to 0.7% in type II diabetes (Ha

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The U.S. Department of Health and Human Services' Physical Activity Guidelines for Amer‐ icans (U.S. Department of Health and Human Services, 2008), suggest that adults over age 18 years have up to 150 min/week of moderate-intensity, or 75 min/week of vigorous aerobic physical activity, or an equivalent combination of the two. In addition, the guidelines sug‐ gest that adults also do muscle-strengthening activities that involve all major muscle groups two or more days per week. Studies included in the meta-analysis of effects of exercise inter‐ ventions on glycemic control (Boulé NG. et al., 2001). The DPP lifestyle intervention, which included 150 min/week of moderate intensity exercise, had a beneficial effect on glycemia in those with prediabetes. Therefore, it seems reasonable to recommend that people with dia‐

In patients who are in poor metabolic control, vigorous exercise may precipitate ketoacido‐ sis because of the exercise-induced increase in the counter-regulatory hormones. On the oth‐ er hand, there is an excessive amount of insulin in the body, the hepatic glucose production in response to excess muscle consumption could be insufficient, and symptoms of hypogly‐

When people with type 1 diabetes are deprived of insulin for 12–48 h and becomeketotic, exercise can worsen hyperglycemia and ketosis (Berger M, Berchtold P., et al., 1977); there‐ fore, vigorous activity should be avoided in the presence of ketosis. However, it is not neces‐ sary to postpone exercise based simply on hyperglycemia, provided the patient feels well

In individuals taking insulin and/or insulin secretagogues, physical activity can cause hypo‐ glycemia if medication dose or carbohydrate consumption is not altered. For individuals on these therapies, additional carbohydrate should be ingested if pre-exercise glucose levels are <100 mg/dl (5.6mmol/l). Hypoglycemia is rare in diabetic individuals not treated with insu‐ lin or insulin secretagogues, and no preventive measures for hypoglycemia are usually ad‐

It is therefore desirable that every person with diabetes planning or having physical exercise carry a glucose or sacharose preparation in form of tablets, jelly or candy or sugar in the form of cubes, candy, juice or soda. If hypoglycemias occur frequently, the entire dose insu‐

The enhanced energy expenditure resulting from exercise increases the need for additional protein which should be met by increased consumption of nutritionally balanced diet. A small amount of additional protein may be required for muscle growth resulting from

Physical activity can acutely increase urinary protein excretion. However, there is no evi‐ dence that vigorous exercise increases the rate of progression of diabetic kidney disease, and

betes try to follow the physical activity guidelines for the general population.

TKK. et al., 1998).

cemia might ensue.

vised in these cases.

lin should be reduced by 10-15%.

chronic physical conditioning.

and urine and/or blood ketones are negative.

A proper nutrition and physical activity is essential for the prevention of arterial hyperten‐ sion in diabetic patients. Hypertension, which is predictive of progression of micro- as well as macrovascular complications of diabetes, can be prevented and managed with interven‐ tions including weight loss, physical activity, moderation of alcohol intake, and diets such as DASH (Dietary Approaches to Stop Hypertension). The DASH diet emphasized fruits, vege‐ tables, and low-fat dairy products; included whole grains, poultry, fish, and nuts; and was reduced in fats, red meat, sweets, and sugar-containing beverages Treatment of high-normal blood pressure (systolic or diastolic blood pressure consistently above the 90th percentile for age, sex, and height) should include dietary intervention and exercise aimed at weight con‐ trol and increased physical activity, if appropriate(Chobanian AV., et al. 2003,*Sacks FM., et al. 2001, Appel LJ., et al. 2006)*.

If target blood pressure is not reached with 3–6 months of lifestyle intervention, pharmaco‐ logic treatment should be considered (Standards of Medical Care in Diabetes—2012)

In individuals with diabetes and macroalbuminuria, reducing protein from all sources to 0.8 g/kg body wt/ day has been associated with slowing the decline in renal function (Franz MJ., et al 2002, Hansen H., et al 2002 ) ; however, such reductions in protein need to maintain good nutritional status in patients with chronic renal failure (Meloni C., et al 2002)

Although several studies have explored the potential benefit of plant proteins in place of an‐ imal proteins and specific animal proteins in diabetic individuals with microalbuninuria, the data are inconclusive. (Wheeler ML., et al 2002)

Medical nutrition therapy is important in preventing diabetes, managing existing diabetes, and preventing, or at least slowing, the rate of development of diabetes complications (Nu‐ trition Recommendations and Interventions for Diabetes, 2008).

#### **12. Nutritional management of exercise and sport**

A regular physical activity improves glucose tolerance, increases muscle mass, reduces body fat mass and increases the number of insulin receptors and glucose entry into cells. A blood flow to the muscle and expansion of capillary space are stimulated during physical activity, which allows a better flow of insulin to muscle cells. (Zergollern Lj., et al., 1994) Regular physical exercise improves insulin resistance and reduction of triglyceride levels and in‐ creases total HDL and HDL2 concentration; it also helps in lowering blood pressure. It re‐ duces mortality in type I diabetes and may reduce HbA1c up to 0.7% in type II diabetes (Ha TKK. et al., 1998).

Initial therapy should consist of optimization of glucose control and MNT using a Step 2 AHA diet (American Heart Association, 2010 Dietary Guidelines) aimed at a decrease in the amount of saturated fat in the diet. People diagnosed with type 1 diabetes in childhood have a high risk of early subclinical (Krantz JS et al, 2004, Järvisalo MJ et al, 2004, Haller MJ., 2004), and clinical (Orchard TJ., et al. 2001) CVD. Although intervention data are lacking, the AHA categorizes children with type 1 diabetes in the highest cardiovascular risk group and recommends both lifestyle and pharmacologic treatment for those with elevated LDL cho‐ lesterol levels (Kavey RE et al, 2006; McCrindle BW et al, 2007). Initial therapy should be with a Step 2 AHA diet, which restricts saturated fat to 7% of total calories and restricts diet‐ ary cholesterol to 200 mg/day. Data from randomized clinical trials in children as young as 7 months of age indicate that this diet is safe and does not interfere with normal growth and

A proper nutrition and physical activity is essential for the prevention of arterial hyperten‐ sion in diabetic patients. Hypertension, which is predictive of progression of micro- as well as macrovascular complications of diabetes, can be prevented and managed with interven‐ tions including weight loss, physical activity, moderation of alcohol intake, and diets such as DASH (Dietary Approaches to Stop Hypertension). The DASH diet emphasized fruits, vege‐ tables, and low-fat dairy products; included whole grains, poultry, fish, and nuts; and was reduced in fats, red meat, sweets, and sugar-containing beverages Treatment of high-normal blood pressure (systolic or diastolic blood pressure consistently above the 90th percentile for age, sex, and height) should include dietary intervention and exercise aimed at weight con‐ trol and increased physical activity, if appropriate(Chobanian AV., et al. 2003,*Sacks FM., et*

If target blood pressure is not reached with 3–6 months of lifestyle intervention, pharmaco‐

In individuals with diabetes and macroalbuminuria, reducing protein from all sources to 0.8 g/kg body wt/ day has been associated with slowing the decline in renal function (Franz MJ., et al 2002, Hansen H., et al 2002 ) ; however, such reductions in protein need to maintain

Although several studies have explored the potential benefit of plant proteins in place of an‐ imal proteins and specific animal proteins in diabetic individuals with microalbuninuria, the

Medical nutrition therapy is important in preventing diabetes, managing existing diabetes, and preventing, or at least slowing, the rate of development of diabetes complications (Nu‐

A regular physical activity improves glucose tolerance, increases muscle mass, reduces body fat mass and increases the number of insulin receptors and glucose entry into cells. A blood flow to the muscle and expansion of capillary space are stimulated during physical activity, which allows a better flow of insulin to muscle cells. (Zergollern Lj., et al., 1994) Regular

logic treatment should be considered (Standards of Medical Care in Diabetes—2012)

good nutritional status in patients with chronic renal failure (Meloni C., et al 2002)

development

480 Type 1 Diabetes

*al. 2001, Appel LJ., et al. 2006)*.

data are inconclusive. (Wheeler ML., et al 2002)

**12. Nutritional management of exercise and sport**

trition Recommendations and Interventions for Diabetes, 2008).

The U.S. Department of Health and Human Services' Physical Activity Guidelines for Amer‐ icans (U.S. Department of Health and Human Services, 2008), suggest that adults over age 18 years have up to 150 min/week of moderate-intensity, or 75 min/week of vigorous aerobic physical activity, or an equivalent combination of the two. In addition, the guidelines sug‐ gest that adults also do muscle-strengthening activities that involve all major muscle groups two or more days per week. Studies included in the meta-analysis of effects of exercise inter‐ ventions on glycemic control (Boulé NG. et al., 2001). The DPP lifestyle intervention, which included 150 min/week of moderate intensity exercise, had a beneficial effect on glycemia in those with prediabetes. Therefore, it seems reasonable to recommend that people with dia‐ betes try to follow the physical activity guidelines for the general population.

In patients who are in poor metabolic control, vigorous exercise may precipitate ketoacido‐ sis because of the exercise-induced increase in the counter-regulatory hormones. On the oth‐ er hand, there is an excessive amount of insulin in the body, the hepatic glucose production in response to excess muscle consumption could be insufficient, and symptoms of hypogly‐ cemia might ensue.

When people with type 1 diabetes are deprived of insulin for 12–48 h and becomeketotic, exercise can worsen hyperglycemia and ketosis (Berger M, Berchtold P., et al., 1977); there‐ fore, vigorous activity should be avoided in the presence of ketosis. However, it is not neces‐ sary to postpone exercise based simply on hyperglycemia, provided the patient feels well and urine and/or blood ketones are negative.

In individuals taking insulin and/or insulin secretagogues, physical activity can cause hypo‐ glycemia if medication dose or carbohydrate consumption is not altered. For individuals on these therapies, additional carbohydrate should be ingested if pre-exercise glucose levels are <100 mg/dl (5.6mmol/l). Hypoglycemia is rare in diabetic individuals not treated with insu‐ lin or insulin secretagogues, and no preventive measures for hypoglycemia are usually ad‐ vised in these cases.

It is therefore desirable that every person with diabetes planning or having physical exercise carry a glucose or sacharose preparation in form of tablets, jelly or candy or sugar in the form of cubes, candy, juice or soda. If hypoglycemias occur frequently, the entire dose insu‐ lin should be reduced by 10-15%.

The enhanced energy expenditure resulting from exercise increases the need for additional protein which should be met by increased consumption of nutritionally balanced diet. A small amount of additional protein may be required for muscle growth resulting from chronic physical conditioning.

Physical activity can acutely increase urinary protein excretion. However, there is no evi‐ dence that vigorous exercise increases the rate of progression of diabetic kidney disease, and there is likely no need for any specific exercise restrictions for people with diabetic kidney disease (Mogensen CE., 2002).

Proteins are an essential nutrient, necessary for normal growth and development in child‐ hood. The recommended intake is 15% of total caloric daily intake in older children and 20% in younger children. The daily requirements are about 1.5g/kg for preschool children for and somewhat less -1g/kg for the children in school age –e.g., until the period of rapid growth during puberty, when the requirements increase again. Only in poorly controlled diabetes or in a period of recovering from ketoacidosis, the amount of protein should be greater than 2g/kg. Variable dietary proteins may influence metabolic control by altering gluconeogenic substrate availability as well as insulin and contra-regulatory hormone secre‐ tion. Excessive protein intake has also been implicated in the pathogenesis of diabetic renal disease. In individuals with diabetes and macroalbuminuria, reducing protein from all sour‐ ces to 0.8 g • kg body wt−1 • day−1 has been associated with slowing the decline in renal

Nutritional Management in Type 1 Diabetes Mellitus

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483

Hypertension can be prevented and managed with interventions including weight loss, physical activity, moderation of alcohol intake, and diets such as DASH (Dietary Ap‐ proaches to Stop Hypertension. 2006). If target blood pressure is not reached with 3–6 months of lifestyle intervention, pharmacologic treatment should be considered. Insoluble dietary fibers have little effect on blood glucose and no effects on lipids, but they may in‐ crease satiety and inhibit hunger, thus inducing positive effects in obese diabetic patients.

By complying with a proper and balanced diet, people with diabetes take adequate amount of vitamins and minerals, so there is usually no need for pharmacological supplements. Zinc

[1] American Diabetes Association. Nutrition principles and recommendations in diabe‐

[2] Appel LJ, Brands MW, Daniels SR, Karanja N, Elmer PJ, Sacks FM: Dietary ap‐ proaches to prevent and treat hypertension: a scientific statement from the American

[3] Augustin L: Dietary glycemic index and glycemic load in breast cancer risk: a case

tes (Position Statement). Diabetes Care 2003: 26(Suppl. 1): S51–S61.

replacement is only suggested to be of benefit in helping to heal venous leg ulcer.

Medical Faculty, University of Prishtina, K. Mitrovica, Serbia

Heart Association. 2006, Hypertension 47:296–308

control study. Ann Oncol 12:1533–1538, 2001

function.

**Author details**

**References**

Snežana Marković- Jovanović
