Diet in Diabetes with Heart Disease T
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Diet in Diabetes with Heart Disease T. C. Raghuram INTRODUCTION than simple carbohydrates, present in jam, jellies, sugars, jaggery and sweets. Calories from simple Among the diet-related non-communicable sugars should be restricted to less than 10%. Rice diseases, diabetes and coronary artery disease and wheat have similar glycaemic index. (CAD) account for high morbidity and mortality. Therefore, rice, if consumed in moderate In recent years, these diseases are emerging as a quantities, is as good as wheat. Certain foods, major public health problem even in developing containing high fat such as milk, ice cream, nuts, countries like India. CAD, cardiomyopathy and though have a low glycaemic index, are not good congestive heart failure are more prevalent among for diabetics with heart disease. Contrary to some diabetics [1]. It is reported that more than 50% of reports[4], suggesting that excess dietary diabetics develop CAD[2]. Many metabolic carbohydrate results in hypertriglyceridaemia thus abnormalities of the diabetic state such as increasing risk for CAD, it has been shown that a hyperinsulinaemia, hyperlipidaemia, increased generous supply of carbohydrate, when given platelet aggregation, coagulation and reduced along with high dietary fibre, has no adverse effect fibrinolysis adversely affects the processes of [5]. In fact, such diets improve glucose tolerance, atherosclerosis and thrombosis, which are the as a result of improved insulin sensitivity. basic underlying mechanisms responsible for various cardiovascular diseases. Special attention Fats should be given to the risk factors such as hypertension, obesity, diabetes, higher serum The diet of an average Indian is usually high in lipids, sedentary habits and smoking, which are carbohydrates and low in fat. Thus, the traditional known to enhance these processes. Diet plays an Indian diet is ideally suited for a diabetic with important role in all these risk factors, except for heart disease. However, in recent years, with smoking and sedentary activity and can, in fact, increasing affluence and urbanisation, there has modify the risk. It is therefore important to been an increase in fat intake with a concomitant consider and comprehend dietary issues and reduction in carbohydrates. A high fat diet formulate guidelines, which will help in increases body weight and adversely affects management as well as in the prevention of these glucose tolerance and insulin sensitivity. It also diseases. In this article, an attempt is made to increases serum lipids and atherosclerosis. In provide dietary guidelines for diabetics with heart addition, diabetics generally have hyperlipidaemia. disease, particularly emphasising the control of Therefore, special attention should be given in dietary factors, which are aetiologically related to determining the quality and quantity of fat in the hyperglycaemia and hyperlipidaemia. diet of a diabetic with heart disease [6]. Healthy dietary practices, recommended for Apart from visible fats derived from vegetable oils normal population, also hold good for diabetics and animal fats ((butter, ghee), invisible fats from with heart disease, except for restriction of foods cereals, pulses, nuts, oil seeds, flesh foods, milk which increase blood glucose and serum lipids. and milk products also provide half of the fat The macronutrients (carbohydrates, fats, proteins) requirements in our diet. Generally, visible and and micronutrients (vitamins and minerals) should invisible fats derived from all plant foods, except be provided in adequate amounts, as suggested in coconut and palm kernel, mainly provide balanced diets, to meet the physiological needs of unsaturated fats, either mono (MUFA) or the body [3]. polyunsaturated fatty acids (PUFA), which have no deleterious effect on serum lipids, when taken Carbohydrates in moderate quantities. Fats from animal sources on the other hand, except from fish liver, are rich Generally, in Indian diets, carbohydrates provide sources of saturated fats. The saturated fats include 60-65% calories. Diabetics with heart disease need coconut oil, hydrogenated oils (vanaspati) and fats not restrict carbohydrate intake, but they may have from animal sources. Groundnut and olive oil are to alter the type of carbohydrate in their diet. rich sources of MUFA, whereas cotton seed, corn, Complex carbohydrates, present in cereals and sunflower and safflower oils are rich sources of pulses have a low glycaemic index and are better PUFA. Sesame and rice bran contain both MUFA and PUFA. From National Institute of Nutrition, Indian Council of Medical Research, Jamai Osmania, Hyderabad-500 007. INT. J. DIAB.DEV. COUNTRIES (1995), VOL. 15 123 It is recommended that 15-30% of total calories be Calories derived from fat. For diabetics with heart disease, the fat intake should be restricted to 15% of the Daily caloric requirements are calculated on the total calories. Since 50% of fat requirements are basis of age, sex, weight, height, nature of physical met form invisible fats, for a person on 2400 Kcal, activity and physiological needs [10]. The 20 g of visible fat will be enough. These fat recommended caloric requirement for an calories could be derived equally from saturated, undernourished (body mass index <18.5) is 40 polyunsaturated and monounsaturated fats. Kcal/kg ideal body weight, for normal (BMI 18.5- However, the saturated fat should not exceed 8- 25) is 30 Kcal and for overweight (BMI > 25) is 10% of the total calories and PUFA 6-8% of 20 Kcal/kg ideal body weight. The calculated calories. As a result, the fat intake should ensure caloric requirement should allow the patient to polyunsaturated/saturated (P/S) ratio of 0.8 to 1. achieve normal BMI by either losing or gaining Higher (>12% calories) intake of PUFA, apart body weight. A person above the age of 50 years from reducing LDL-cholesterol, also results in an requires 10% less calories for each decade undesirable reduction in HDL-cholesterol. increase in age. In addition to saturation of oils, the ratio of Obesity is an established risk factor for several linoleic acid (LS n-6) and alpha-linolenic acid chronic diseases [11]. It not only increases glucose (ALNA n-3) is also important, as these two intolerance, but also increases hyperlipidaemia and essential fatty acids contribute to the formation of heart disease, particularly hypertension. It is eicosonoids. However, eicosonoids formed from important for obese individuals to maintain BMI n-3 PUFA have more effective antithrombotic and in the normal range by reducing calories and vasodilatory properties than that formed from n-6 increasing physical activity. Reduction in body PUFA. Therefore, it is recommended that in our weight improves glucose tolerance and reduces diet, LA/ALNA ratio is around 5-10, LA blood pressure. In addition, it also brings about a contributing a minimum 3% energy and ALNA favourable lipid profile, reducing total cholesterol contributing a minimum 0.5% energy. Based on and LDL-cholesterol and increasing HDL- these guidelines, diabetics with heart disease can cholesterol. Although, for weight reduction, it is take groundnut oil or ricebran oil singly or a advisable to combine diet restriction with exercise, combination of safflower or sunflower oil with a diabetic with heart disease, should first consult a either palm or mustard oil in moderate amounts physician before undertaking the exercise to [7]. determine the nature, frequency and duration of exercise. Fish provides long chain n-3 fatty acids, which have beneficial effects on platelet aggregation and Fibre triglycerides. Therefore, non-vegetarians can take 100-200g of fish twice a week instead of red meat, The beneficial effects of dietary fibre in the dietary shrimps, prawns and egg yolk, which add management of diabetes and CHD have been well- saturated fat and cholesterol to the diet. Though recognised [12]. Among the two types, soluble the upper limit for dietary cholesterol is fibre (pectin, gums and mucilages) present in 300mg/day [8], it is better that diabetics with heart vegetables, fruits and legumes, is more effective in disease restrict this limit to 100-150 mg/day. controlling blood glucose and serum lipids than Hence, vegetarians can take fenugreek, mustard, insoluble fibre (cellulose, hemicellulose, lignin) green leafy vegetables, blackgram, wheat, which present in cereals and millets. Apart from soluble are rich sources of this fatty acid. fibre, vegetables, fruits and legumes also provide antioxidants and n-3 fatty acids; their intake Proteins should therefore be encouraged. Traditional Indian Foods, generally prepared with whole grains, It is generally recommended that 15-20% of the pluses and vegetables, will have more fibre and total calories be derived from proteins. The antioxidants. Foods with high dietary fibre, recommended dietary allowance for protein is 0.8- particularly with soluble fibre, have a low 1 g/kg body weight. Proteins from vegetable glycaemic index and are also effective in reducing sources are better than from flesh foods as they blood glucose and serum lipids. Compared to fast provide fibre, and do not contribute cholesterol to foods and modern refined foods, our traditional the diet. The added advantage is that progression foods are more useful to patients with diabetes and of renal disease is lower with vegetable proteins cardiovascular disease. It is preferable to have than those from animal foods [9]. 25g/1000 Kcal or 40 g of fibre in our daily diet. INT. J. DIAB.DEV. COUNTRIES (1995), VOL. 15 124 Salt Beverages Salt intake is closely associated with hypertension In view of its caffeine content, increased coffee and beneficial effects of salt restriction in the consumption is associated with increase in blood management of hypertension has been pressure and arrhythmias. It is better to restrict demonstrated. Although, daily salt requirements coffee consumption to 3 cups per day. Since tea are only around 6-7 g, Indians are habituated to contains less caffeine than coffee, it is preferable take higher amounts of salt, ranging from 10 to 15 for diabetics with heart disease to consume tea g/day. Therefore, even normal subjects should cut rather than coffee.