1. Postgraduate Diploma in Diabetes Education
(PDDE
Nutrition therapy: Dietary advice in case of
complications
2-Estimated Energy Requirements
among Diabetic Patients
Dr. Siham Mohamed Osman Gritly

2. A health food with low Calories
Dr. Siham Mohamed Osman Gritly
the calorie content of the diet for all diabetics should
be set at a level which will permit them to maintain
their desired body weight and in children and
adolescents allow for a normal rate of growth and

3. Calorie Requirement Based on
Weight/age
Category Calorie requirement
Over weight 20 Kcals/Kg/day
Ideal weight 30 Kcals/Kg/day
Under weight 40 Kcals/Kg/day
Elderly person above 50 years 10% less calories for each
additional decade
Children - Ist year 1000 calories
For girls 1 – 12 years 1000 + 100 calories per year of
age up to 12 years
For boys 1 – 12 years 1000 + 125 calories per year of
age after 12 years
Dr. Siham Mohamed Osman Gritly

4. Guide to calorie allocation (calories/kg body
weight)
* Adapted from Meal Planning: American Dietetic Association 1997
BMI
Inactive Moderately
active
Very active
Overweight 20 20 - 25 30
Normal weight 20 25 35 – 40
Underweight 40 - 50
Dr. Siham Mohamed Osman Gritly

5. Carbohydrates and Diabetes Mellitus
• The present recommendation is to provide
complex carbohydrates and fiber and
restricted fat.
• Carbohydrates should provide 50 – 60 per cent
of energy
• Complex carbohydrates should account for
approximately 2/3 of total carbohydrate.
• 60 – 70% should be complex carbohydrate
• 30 – 40% should be simple carbohydrate
• adults with diabetes should eat no more than 200
grams per day
Dr. Siham Mohamed Osman Gritly

6. Complex carbohydrates are composed of
glucose monomers in long, complex chains
Dr. Siham Mohamed Osman Gritly
Advantages of complex
carbohydrates
Stimulates glucose use
(glycolysis and
glycogenesis) in many
tissues.
Increases tissue insulin
sensitivity.
Increases insulin receptor
number.

7. Simple carbohydrates from commonly used food tend
to raise blood glucose more than complex carbohydrates
from starchy foods.
• Simple carbohydrates are sugars found naturally in
food. They can also be added to food. They include:
• Candy
• Fruit
• Milk
• Sugar-sweetened products
• Table sugar
• Vegetables
• Fiber High fiber intake improves glycemic control and
reduces insulin requirements
Dr. Siham Mohamed Osman Gritly

8. The glycaemic index (GI)
represents a ranking system relative to the effect that
consumption of 50 grams of particular carbohydrates that
influence blood glucose within 2 hours.
• glycemic index; Carbohydrates which produce
a large increase in blood glucose
concentration, in response to a standard
amount of carbohydrate (50g), are classified as
having a high glycemic index
• The carbohydrate in watermelon or grapes,
for example, both have a high GI (food
which have refined sugars). Foods high in
fiber such as beans have low GI
Dr. Siham Mohamed Osman Gritly

9. Glycemic Index values
A glycemic index GI value tells only how rapidly a
particular carbohydrate turns into sugar
• The values that used to rank glycemic index of
food as follows;-
*70 or more------high GI
*69-55------------medium GI foods
*55 or less--------low GI foods
Factors other than CHO might influence the GI;-
*physical form (coarse or fine)
*serving mode (raw or cooked)
Dr. Siham Mohamed Osman Gritly

10. • Foods with low glycemic indexes include;
• oats, barley, beans, lentils, legumes, pasta,
bread, apples, oranges, milk, yogurt, and ice
cream.
• Fiber, fructose, lactose, and fat are dietary
constituents that tend to lower glycemic
response.
Dr. Siham Mohamed Osman Gritly

11. Glycemic load (GL)
• The glycemic load represents a ranking system
relative to the effect that eating a carbohydrates
food has on the blood glucose level, but also
includes the portion size
• The glycemic load (GL) is a relatively new way
to assess the impact of carbohydrate consumption
that takes the glycemic index into account,
• glycemic load gives a fuller picture than does
glycemic index alone
Dr. Siham Mohamed Osman Gritly

12. Glycemic index and glycemic load
• glycemic index is the rate at which food is
converted into glucose, glycemic load is the
total amount (load) of glucose provided by the
food. Glycemic index is an absolute value
• while glycemic load depends on the serving
size of the food. Glycemic load values are
always quoted in reference to a serving size in
grams.
Dr. Siham Mohamed Osman Gritly

13. Glycemic load values
• Values are used to rank the glycemic load
food;-
*20 or more----high GL
*19-11----------medium GL food
*10 or less------low GL foods
Foods that have a low GL almost always have a
low GI is more healthful source of CHO.
Dr. Siham Mohamed Osman Gritly

14. The glycemic load of a food is calculated by multiplying the
absolute GI value by the grams of available carbohydrate in
the serving, and then dividing by 100.
• The glycemic load can be calculated by the following
equation;-
• GL= GI gms of CHO in one serving 100
• Note that Available Carbs is equal to the total carbohydrate
content minus the fiber content.
• For example, a 225 g (1 cup) serving of Bananas with a GI of
52 and a carbohydrate content of 45.5 g (51.4 g total
carbohydrate - 5.9 g fiber) makes the calculation GL = 52 *
45.5 / 100 = 24, so the GL is 24.
• Adapted from; www.glycemicgourmet.com/how-calculate-glycemic-index.htmlDr. Siham Mohamed Osman Gritly

15. Exercise;- calculate the Glycemic Load of the
following carbohydrates;-
adapted from; Melvin H Williams 2010; Nutrition for Health, Fitness and
Sport.
COH Glycemic index CHO in grams Gycemic loadL
1-baked potato 1
cup
85 57 ?
2-white bread 1
slice;-
70 10 ?
3-orange 1 medium 44 15 ?
4-fructose 1 tsp 23 5 ?
5-wafers (5 cookies) 77 15 ?
Dr. Siham Mohamed Osman Gritly

16. Hormones that responsible for carbohydrate
regulation; Response of hypothalamus to blood
glucose level
Dr. Siham Mohamed Osman Gritly
If the sugar levels in the blood fall far below
their usual range, the brain (hypothalamus)
responds by stimulating;
*the adrenal glands to release, 1-
adrenaline or norepinephrine, 2-epinephrine
and 3-cortisol,
*-the pancreas to release glucagon and
insulin, Insulin is a hormone produced in
special cells in the pancreases which
enables body cells to absorb glucose, for
energy production, glucagon increase the
rate of gluconeogenesis in the liver and help
to increase blood glucose levels
*- the pituitary gland to release growth
hormone, all of which cause the liver to
regulate glucose into the blood.

17. The pancreas
insulin and glucagon from the pancreas
Dr. Siham Mohamed Osman Gritly
Glucose + Insulin  Inside
Cells
insulin: a hormone
secreted by special cells in
the pancreas in response to
increased blood glucose
concentration.

18. Dr. Siham Mohamed Osman Gritly
The primary role of insulin is
to control the transport of
glucose from the bloodstream
into the muscle and fat cells
Insulin promotors
Tissue glycolysis
Fatty acid synthesis
Intracellular deposition of
glucose through stimulation of
glycogen synthesis.
Insulin accelerates hepatic
glycolysis by increasing levels
of the enzymes glucokinase

19. glucagon increase the rate of
gluconeogenesis in the liver and help to
increase blood glucose levels
Dr. Siham Mohamed Osman Gritly
glucagon: a hormone that is secreted by special cells in the
pancreas in response to low blood glucose concentration and elicits
release of glucose from liver glycogen stores

20. The Pituitary gland
human growth hormone from pituitary
gland
Dr. Siham Mohamed Osman Gritly
*- the pituitary gland
to release growth
hormone, all of which
cause the liver to
regulate glucose into
the blood

21. The Adrenal Gland
adrenalin, epinephrine and cortisol from the
adrenal glands
Dr. Siham Mohamed Osman Gritly
the adrenal glands to release,
1-adrenalin or norepinephrine, is
released in greater amounts during
physical activity increased energy
in the form of glucose and free
fatty acids
2-Epinephrine stimulate the liver
to release glucose and accelerates
the use of glycogen in the muscle
3-cortisol, release of amino acids
from muscle tissue to provide
substrate to liver for
gluconeogenesis

22. Protein
• Minimum Daily Protein Requirement:
W.H.O. recommends 0.45 grams of protein per
kilogram of ideal body weight per day.
• Maximum Daily Protein Requirement: US
RDA recommends 0.8 grams of protein per
kilogram of ideal body weight per day.
Dr. Siham Mohamed Osman Gritly

23. Protein and Diabetes Mellitus
• Protein should provide 12 – 20% of energy intake
• An additional 30 g may be necessary during pregnancy and
lactation
• Protein requirement is increased in malnutrition, surgery or
wound healing.
• In insulin dependent diabetics adequate dietary protein (1 –
1.5g/kg body weight) is necessary for growth and
development.
• In diabetic nephropathy, protein restriction may vary
between 0.4 – 0.6 g per kilogram
• The source of protein is as important as amount.
• Protein from vegetable source is preferable to that from
animal sources
Dr. Siham Mohamed Osman Gritly

24. Fat and Diabetes Mellitus
• The amount and type of fat plays an important
role in the diet of a diabetics.
• Diabetes of all types have a greater incidence
of hyperlipidemia and atherosclerosis
Dr. Siham Mohamed Osman Gritly

25. • The present recommendation of total fat is
• 20 – 30% of total calories.
• Saturated, monosaturated and polyunsaturated
fatty acids are given in the ratio of 1 : 1 : 1
• Saturated fats – less than 10%
• polyunsaturated fats – 6 – 8%
• Dietary cholesterol should be less than 300
mgs/day
Dr. Siham Mohamed Osman Gritly

26. energy requirements;
Estimate energy requirement from different
nutrients for diabetic patient
• total food energy
• carbohydrate intakes should contribute 50 – 60
per cent of the total energy,
• Energy from Fat 20 – 30% of total calories
• Energy from Protein contributes to about 12 –
20% of energy intake
Dr. Siham Mohamed Osman Gritly

27. Calculate food energy from different nutrients
for diabetic small woman who exercises;
• example of energy requirement for diabetic small
woman who exercises is about 1200 – 1600
• calculate the requirements in terms of;
• CHO,
• protein
• and fats
• The energy yield per gram is as follows:
• Carbohydrate - 4 Calories,
• Fats - 9 Calories
• Protein - 4 Calories.
Dr. Siham Mohamed Osman Gritly

28. Estimated total calories intake from
Carbohydrate
• Carbohydrate; 50 – 60 % calories
• 60% of 1600 = 960 Calories
• at 4 Calories/gram = 240 4= about grams
• If use minimal requirement;
• 50%of 1600=800 calories
• At 4 calories/gram=800 4= 200 gram
Dr. Siham Mohamed Osman Gritly

29. Estimated total calories from fat
• 20 – 30% of total calories from fat,
• 30% of 1600 calories= 480 calories from fats
• at 9 Calories/gram= 480 9= about 53 grams
of fats/day
Dr. Siham Mohamed Osman Gritly

30. Estimated energy intake from protein
• 12 – 20% of energy intake from protein
• 20% of 1600= 320 Calories from protein
• At 4 Calories/gram= 320 4= 80 grams/day
Dr. Siham Mohamed Osman Gritly

31. Unites for energy expenditure
1 kilojoule (kJ) = 1,000 joules
1 megajoule (MJ) = 1,000,000 joules
1 kilocalorie (kcal)= 1,000 calories or 1 Calorie
(Cal)
1 kcal = 4.184 kJ
1 MJ= 239 kcal
Dr. Siham Mohamed Osman Gritly

32. References
• American Diabetes Association. Standards of medical care in diabetes--2011.
Diabetes Care. 2011 Jan;34 Suppl 1:S11-61
• Sareen Gropper, Jack Smith and James Groff, Advanced Nutrition and Human
Metabolism, fifth ed. WADSWORTH
• Melvin H Williams 2010; Nutrition for Health, Fitness and Sport. 9th ed, McGraw
Hill
•
• Heymsfield, SB.; Baumgartner N.; Richard and Sheau-Fang P. 1999. Modern
Nutrition in Health and Disease; Shils E Maurice, Olson A. James, Shike
Moshe and Ross A. Catharine eds. 9th edition
• Guyton, C. Arthur. 1985. Textbook of Medical Physiology. 6th edition, W.B.
Company
• FAO/WHO/UNU expert consultation (WHO, 1985) report
• Ellie Whitney and Sharon Rady Rolfes; Under standing Nutrition, Twelfth Edition.
2011, 2008 Wadsworth, Cengage Learning
Dr. Siham Mohamed Osman Gritly

33. • Name five foods which have low glycemic
index ?
• Mention five foods which can be consumed in
unlimited amounts by a diabetic ?
Dr. Siham Mohamed Osman Gritly