Clinical

Volume 8 Number 4 Fall 2009

Practical Information for Primary Care

An Official Journal of the

American Diabetes

Association

DIABETES.ORG/CLINICALDIABETES

( Middle East Edition )

Nutritional Recommendations for Management of Diabetes in the Arab Countries

MONIRA AL-AROUJ, MD1, SAMIR ASSAAD-KHALIL, MD . PHD2 , MEGAHED ABU AL-MAGD, MD3, IBTIHAL FAHDIL , MD4, MOHAMED FAHMY , MD , PHD5, SHERIF HAFEZ, MD, FACP6, MOHAMED HASSANEIN , FRCP7 , MAHMOUD ASHRAF IBRAHIM, MD8, SUHAIL KISHAWI, MD9, ABDULRAZZAQ AL-MADANI, MD10, INGRID MÜHLHAUSER , MD , PHD11, SUSAN MCLAUGHLIN , BS, RD,CDE12, ABDULLAH BEN NAKHI, MD1, KHALED TAYEB, MD13

82009

2009

181Volume 8, Number 4, 2009 • CLINICAL DIABETES (MIDDLE EAST EDITION)

L O C A L A R T I C L E S

From the 1 Dasman Center for Research and Treatment of Diabetes, Kuwait; 2 Department of Internal Medicine & Diabetes, Faculty of Medi-cine , Alexandria University , Egypt , 3 Depart-ment of Internal Medicine & Diabetes, Faculty of Medicine, Mansura University, Mansura, Egypt ; 4 Director , Non Communicable Diseases NCD Department , East Mediterranean Office EMRO of the WHO , Cairo , Egypt , 5 Department of Internal Medicine & Endocrinology, Faculty of Medicine, Ain Shams University, Cairo, Egypt , 6 Department of Internal Medicine & Diabetes, Faculty of Medicine, Cairo University, Cairo, Egypt , 7 Consultant Diabetes & Endocrinol-ogy, N Wales, UK , 8Egyptian Diabetes Center, Cairo, Egypt; 9 Ministry of Health, Palestinian National Authority, Shifa Hospital, Gaza, Pal-estine; 10Dubai Hospital, Dubai, United Arab Emirates; 11Prof of Medicine , University of Hamburg , Germany , 12 Faculty, The Nebraska Medical Center, Omaha, Nebraska, USA,13Al-Nour Hospital, Mekkah, Saudi Arabia.Address correspondence and reprint requests to Mahmoud Ashraf Ibrahim, MD, 19 Nasouh St., Zeitoun, Cairo 11321 , Egypt. E-mail: mah-moud@arab-diabetes.com. Nutrition is an essential component in the treat-ment of diabetes irrespective of its type. Never-theless, nutrition advice given by health profes-sionals to patients is often inadequate. This is partly due to the lack of time for the health care providers; however it is also often due to lack of appropriate nutrition knowledge and how to make healthy food choices (Appendix 1). Medical Nutrition Therapy (MNT) is important in preventing diabetes, managing existing dia-betes, and eventually preventing, minimizing or at least postponing the development of diabetes complications. It is therefore, important at all levels of diabetes prevention. MNT is also an integral component of diabetes self-manage-ment education (1). The goal of the present rec-ommendations is to make people with diabetes and health care providers in the Arab countries aware of the beneficial impact of nutrition in-terventions. Achieving nutrition-related goals requires a coordinated team effort that includes the person with diabetes and involves him or her in the decision-making process (2).

Prevalence of diabetes and obesity in the Arab countries In 2007, the Middle East and North Africa Re-gion( MENA)had the highest prevalence of dia-betes in the world with 9.2%. The explosion of diabetes in the MENA Region is mainly due to type 2 diabetes. As with many other countries with high diabetes prevalence, the onset of type 2 diabetes tends to occur at a relatively young age. Studies performed in six countries - Bah-rain, Egypt, Kuwait, Oman, Saudi Arabia and United Arab Emirates - have shown their current

diabetes prevalence to be among the world’s 10 highest, and a similar situation applies for the prevalence of impaired glucose tolerance (IGT) of some of these countries. The ageing of popu-lations, together with socio-economic changes and westernization, have combined to cause a dramatic increase in diabetes prevalence.

The MENA Region will continue to have the highest prevalence rate with 10.4% of its adult population affected by diabetes in 2025. Six countries – United Arab Emirates, Saudi Arabia, Bahrain, Kuwait, Oman and Egypt – are pro-jected to remain in the top 10 for countries with the highest diabetes prevalence in the world by 2025. In addition, the regional prevalence of IGT in the MENA Region was 7.0%, in 2007 and is expected to increase to 9% in 2025 (3).

Obesity is a growing and serious health problem in the Arab world. Data reported from several Arab countries show alarming prevalence rates of both overweight and obesity. Changes in the life-style, dietary habits, physical activity and the so-cial and cultural environment are associated with the occurrence of obesity. Al Nozha et al showed that in 17,232 Saudi subjects, the prevalence of overweight and obesity was 36.9% and 35.6% re-spectively (4). Data from the Eastern Mediterra-nean Approach for Control of Chronic Non Com-municable Diseases (EMAN), conducted during 2007 in Kuwait, a WHO-EMRO initiative, found 80.2% of the 2940 Kuwaiti subjects aged 20-64 years to be obese or overweight.

Obesity is a known risk factor for type 2 dia-betes. In a study from Jordan, 31% of the study par-ticipants were overweight and 12% were obese (5). In a Kuwaiti study, 334 patients with dia-betes and/or hypertension, 90.4% were over-weight or obese (6).

Equally alarming is the fact that obesity is also affecting children and adolescents. In the Kuwait Nutrition Surveillance System (2007), 17364 subjects below the age of 20 years were screened. Seven percent of pre-school children were obese (<2SD). The incidence of over-weight and obesity in different age groups were as follows; 14.2%, 42.6% and 45.0% in the age groups 5-9, 10-13 and 14-20 years respectively (7). In Gaza, Palestine, in 2002, the prevalence of obesity (BMI > 30 ) was 72.4 % in females and 42.3% in males respectively (8).

Pattern of eating in the Arab countriesFood consumption patterns and dietary habits in this region have changed markedly during the past few decades. There has been an increase in per capita energy and food intake in all coun-tries. Between 1971-1997 daily per capita fat in-take showed an increase ranging from 13.6% in Sudan to 143% in Saudi Arabia (9). In Jordan,

in a study of food consumption patterns, 74.2% reported taking meals irregularly, 47.9% report-ed consumption of colored vegetables and only 31.7% reported taking fruit daily (5).

In Kuwait, a remarkable change in the food con-sumption pattern took place, after the discovery of oil. Traditionally, consumption was of a lim-ited variety of foods, mainly rice, dates, fish and seafood, camel milk, sheep and goat meat and their by-products. Meat was eaten once a week, or as rarely as once a month by the majority, with smaller portions. Beverages were mainly Arabic coffee and milk. Sweetened desserts were served only on special occasions. This is very differ-ent from today, as processed foods are imported from all over the world. Sweets, chocolates, pas-tries and snacks are available in abundance. Fast food, such as burgers, pizza and fried chicken are widely consumed by the younger popula-tion. Normally three meals are eaten per day; light breakfast, lunch (the main meal of the day), and dinner. Energy consumption is around 3010 kcal per capita, which is above the population energy requirements of 2185 kcal per capita per day. This dietary pattern can be applied for all of the Gulf countries (10).

Many changes have occurred in food habits of the Egyptians from early 1950s to the end of the 20th century. The traditional diet was more de-pendent on cereals, dried legumes and preserved foods. Out of necessity, Egyptians perfected a number of food processing techniques over the ages. They preserved cheese, cereals, fruits, leg-umes, vegetables (including dark green leafy vegetables), fish, meat, grains, aromatic seeds and condiments. This is now changing and the traditional diet is being replaced by dishes requiring lengthy preparation and generous amounts of clarified butter, with less attention to the consumption of fresh vegetables. Deep-frying, the use of rich sauces, and rich sweet desserts containing nuts and soaked in heavy syrup is becoming commonplace. This raised the overall intake of sugars and saturated fats. White bread, in many instances, has replaced the traditional high extraction local bread. Many of the nutritionally valuable, traditional food as-sociations are being ignored. For individuals of lower socioeconomic status, changes are related to the need to cope with rising food costs and the inability to afford nutritionally correct choices. However, for them, fresh green vegetables are still frequently consumed (11).

Fasting during the holy month of Ramadan in the Arab countries is associated with a set of tra-ditions related to food causing many people to consume an excess of higher caloric foods dur-ing non-fasting hours that extend from sunset to dawn. Consumption of dried fruits, all kinds of nuts, oriental desserts rich in fat and sugar, as well as the daily cooked meal for breaking

Nutritional Recommendations for Management of Diabetes in the Arab Countries

182 Volume 8, Number 4, 2009 • CLINICAL DIABETES (MIDDLE EAST EDITION)

L O C A L A R T I C L E S

the fast often adds up to a higher calorie content than usual, non fasting, daily intake. Meat and poultry consumption is increased, as families tend to serve meat daily, even if this was not their usual custom..Barriers to the implementation of the nutritional recommendations

These factors were identified as the greatest bar-riers to implementing the nutrition recommena-tions: lack of time, lack of symptoms, lack of ed-ucation (including follow-up), poor self-esteem/lack of empowerment, and misinformation from family/peers/others with diabetes. The primary recommendations for overcoming each of these barriers included individualizing meal plans and planning ahead, teaching about complications, and setting obtainable goals. Adherence to nu-tritional recommendations and exercise was evaluated in a study of 334 Kuwaitis with type 2 diabetes: 63.5% reported no adherence to any form of dietary guidance, 64.4% were not par-ticipating in regular exercise. 90% were over-weight or obese. The main barriers to changing habits were unwillingness (48.6%), difficulty in adhering to a diet that differs from that the rest of the family (30.2%), and attending social gath-erings (13.7%) (6).

Goals of MNT that apply to individuals with diabetes

In essence, the aim of MNT is to help and em-power people with diabetes to identify their priorities and choose a healthier eating pattern. This is achieved through the following:

Address individual nutrition needs, tak-1. ing into account personal and cultural preferences and willingness to change.Achieve and maintain blood glucose lev-2. els appropriate to the individual needs. Maintain a lipid profile & blood pressure levels in the recommended ranges to re-duce the risk of macrovascular and mi-crovascular diseases.Achieve and maintain a normal or near 3. normal body weight. Prevent, minimize or postpone the de-4. velopment of diabetes complications by modifying nutrient intake and lifestyle.Maintain the pleasure of eating by limit-5. ing food choices only when supported by scientific evidence.

Individualized goals of MNT should be applied to specific groups like youth with type 1 diabe-tes, youth with type 2 diabetes, pregnant and lactating women, and the presence of concomi-tant diseases.

Clinical trials/outcome studies of MNT have reported decreases in A1C of about 1% in type 1 diabetes and 1–2% in type 2 diabetes, depend-ing on the duration of the disease (12-13). Meta analysis of studies in non diabetic subjects as well as expert committees reported that in non diabetic subjects, MNT reduces LDL choles-terol by 15–25 mg/dl (14-15). After initiation of MNT, improvements were apparent in 3–6 months. Meta-analysis and expert committees also support a role for lifestyle modification in treating hypertension (16-17).

In overweight and obese insulin resistant indi-viduals, modest weight loss has been shown to improve insulin resistance. Thus, weight loss is

recommended for overweight individuals who have diabetes or are at risk for developing it. Weight loss is an important therapeutic objec-tive for individuals with pre-diabetes or diabetes (19). For weight loss, low-carbohydrate and/or low-fat calorie-restricted diets may be effective in the short term (up to 1 year). The US Nation-al Heart, Lung, and Blood Institute guidelines define overweight as BMI more than 25 kg/m2 and obesity as BMI more than 30 kg/m2 (18). Visceral body fat, as measured by waist circum-ference more than 35 inches (89 cm) in women and more than 40 inches (101.6 cm) in men, is used in conjunction with BMI to assess risk of type 2 diabetes and CVD (18).

The latest ADA/EASD Consensus statement for medical management of type 2 diabetes indicat-ed clearly that a lifestyle intervention program to promote weight loss and increase activity levels should, with rare exceptions, be included as part of diabetes management. Weight loss of as little as 4 kg will often ameliorate hypergly-cemia. However, the limited long-term success of lifestyle programs to maintain glycemic goals in patients with type 2 diabetes suggests that the large majority of patients will require the ad-dition of medications over the course of their diabetes (20). This was also confirmed in the American Diabetes Association Clinical Prac-tice Recommendations 2009. Standard weight loss diets provide 500–1,000 fewer calories than estimated to be necessary for weight mainte-nance and initially result in a loss of about 1–2 lb/ week (approx 0.5-1 Kg) (21)

Primary preventionFor individuals at high risk of developing type 2 diabetes, structured programs that emphasize lifestyle changes can reduce this risk. These in-clude moderate weight loss (7% body weight), regular physical activity (150 min/week), and dietary strategies reducing calories and dietary fat. (22-23)Individuals at high risk for type 2 diabetes should be encouraged to adopt the U.S. Depart-ment of Agriculture recommendation for dietary fiber (14 g fiber/1,000 kcal) and foods contain-ing whole grains (one-half of grain intake)(21).

Genetic susceptibility appears to play a powerful role in the occurrence of type 2 diabetes. How-ever, given that population gene pools shift very slowly over time, the current epidemic of dia-betes likely reflects changes in lifestyle, leading to diabetes. Lifestyle changes characterized by increased energy intake and decreased physical activity appear to have together promoted over-weight and obesity, which are strong risk fac-tors for Type 2 diabetes. Clinical trial data from both the Finnish Diabetes Prevention Study (22) and the Diabetes Prevention Program (DPP) (23) strongly support the potential for moderate weight loss to reduce the risk (or postpone) the onset of type 2 diabetes. In the DPP, subjects in the lifestyle intervention group reported dietary fat intakes of less than 34% of energy at base-line and 28% of energy after 1 year of interven-tion (24) Both the Finnish Diabetes Prevention Study and the DPP focused on reduced intake of calories (using reduced dietary fat as a dietary intervention). Of note, reduced intake of fat, particularly saturated fat, may reduce risk for diabetes by producing an energy-independent improvement in insulin resistance (2), as well as by promoting weight loss.

Diabetes in youthNo nutrition recommendations can be made for the prevention of type 1 diabetes at this time (2). The increase in overweight and obesity in youth appears to be related to the increased prevalence of type 2 diabetes.

Secondary preventionA balanced diet that includes carbohydrates from fruits, vegetables, whole grains, legumes, and complies with the various recommendations to maintain appropriate body weight is encour-aged for good health (25). Monitoring carbo-hydrate, whether by carbohydrate counting, exchanges, or experience-based estimation re-mains a key strategy in achieving glycemic con-trol. The use of glycemic index and load may provide a modest additional benefit over that observed when total carbohydrate is considered alone (Appendix 2). Sucrose-containing foods can be substituted by other carbohydrates in the meal plan, or, if added to the meal plan, covered with insulin or other glucose lowering medica-tions. Care should be taken to avoid excess calo-rie intake. Nutritive sugar alcohols (e.g. sorbitol, erythritol) and nonnutritive sweeteners are safe when consumed within the daily intake levels established by the US Food and Drug Adminis-tration (FDA)(21).

Amount and type of carbohydrate. A 2004 ADA statement addressed the effects of the amount and type of carbohydrate in diabetes management (26) (Appendix 3).

The amount of carbohydrate ingested is usu-ally the primary determinant of postprandial re-sponse, but the type of carbohydrate also affects this response. Foods shown in some studies to have a low glycemic indexes include oats, bar-ley, beans, lentils, legumes, pasta, bread, apples, oranges, milk, yogurt, and ice cream. Fiber, fructose, lactose, and fat are dietary constituents that tend to lower the glycemic response. Poten-tial methodological problems with the glycemic index have been noted (27). In diabetes manage-ment, it is important to match doses of insulin and insulin secretagogues to the carbohydrate content of meals. A variety of methods can be used to estimate the nutrient content of meals, including carbohydrate counting, the exchange system, and experience based estimation. By testing pre and postprandial glucose, many indi-viduals use experience to evaluate and achieve postprandial glucose goals with a variety of foods. The use of food labels has also been found to be an effective tools in carbohydrate counting ( Appendix 4 ).

FiberAs for the general population, people with dia-betes are encouraged to choose a variety of fiber containing foods such as legumes, fiber-rich cereals (more than 5 g fiber/serving), fruits, vegetables, and whole grain products. Special attention should be paid to the type of bread consumed, as a type like the traditional Egyp-tian bread has more health benefits than than the refined white bread. This may be significant, as people in most Arab countries rely a lot on bread as a dietary staple.

Dietary fat in diabetes managementADA Recommendations limit saturated fat to below 7% of total calories. Intake of trans fat should be minimized or better avoided. Dietary

183Volume 8, Number 4, 2009 • CLINICAL DIABETES (MIDDLE EAST EDITION)

L O C A L A R T I C L E S

cholesterol should be limited to less than 200 mg/day. Two or more servings of fish per week to ensure an adequate supply of omega oils are suggested and thus preferred over meat (1).

A modified Mediterranean diet, in which polyun-saturated fatty acids were substituted for monoun-saturated fatty acids, was associated with lower mortality in elderly Europeans (28).

Protein in diabetes managementFor individuals with diabetes and normal renal function, there is insufficient evidence to sug-gest that usual protein intake (15–20% of en-ergy) should be modified. In individuals with type 2 diabetes, ingested protein can increase insulin response without increasing plasma glu-cose concentrations. Therefore, protein should not be used to treat acute or prevent nighttime hypoglycemia. High-protein diets are not rec-ommended as a method for weight loss at this time. The dietary intake of protein for individu-als with diabetes is similar to that of the general public and usually does not exceed 20% of en-ergy intake. A number of studies in healthy indi-viduals and in individuals with type 2 diabetes have demonstrated that glucose produced from ingested protein does not increase plasma glu-cose concentration but does produce increases in serum insulin responses (2).

Nutrition for type 1 DiabetesFor individuals with type 1 diabetes, insulin therapy should be integrated into an individual’s dietary and physical activity pattern. Individuals using rapid-acting insulin by injection or insulin pump should adjust insulin doses based on the carbohydrate content of the meals and snacks. The first nutrition priority for individuals requir-ing insulin therapy is to integrate an insulin regi-men into their lifestyle. With the many insulin options now available, an appropriate insulin regimen can usually be developed to conform to an individual’s preferred meal routine, food choices, and physical activity pattern. For indi-viduals receiving basal-bolus insulin therapy, the total carbohydrate content of meals and snacks is the major determinant of bolus insulin doses (29).

Nutrition for type 2 diabetesIndividuals with type 2 diabetes are encouraged to implement lifestyle modifications that reduce intake of calories, saturated and trans fatty acids, cholesterol, and sodium and to increase physical activity in an effort to improve glycemia, dyslip-idemia, and blood pressure. Glucose monitoring can be used to determine whether adjustments in foods and meals will be sufficient to achieve blood glucose goals or if medication(s) needs to be combined with MNT (1). Nutrition for pregnancy and lactation with dia-betes

Weight loss is not recommended during preg-nancy. GDM is a risk factor for subsequent type 2 diabetes. After delivery, lifestyle modifications aiming at reducing weight and increasing physi-cal activity are recommended. A large clinical trial reported that treatment of GDM with nutrition therapy, blood glucose monitoring, and insulin therapy as required for glycemic control reduced serious perinatal complications without increas-ing the rate of cesarean delivery as compared with routine care (30).

Nutrition for elders with diabetesObese elders with diabetes may benefit from modest calorie restriction. A daily multivitamin supplement may be appropriate in the presence of deficiencies.

Tertiary preventionReduction of protein intake to 0.8 –1.0 g per kg body wt per day may have an impact on renal insufficiency. MNT that favorably affects cardi-ovascular risk factors may also have a favorable effect on microvascular complications such as retinopathy and nephropathy.

Appendix 1Making Healthy Food Choices

This could be somewhat confusing; here are a few tips for making healthy food choices:

• Choose more vegetables and fruits.• Pick from the rainbow of colors available

to maximize variety. • Eat non-starchy vegetables such as spin-

ach, carrots, broccoli or green beans with meals. • Choose whole grain foods rather than

processed grain products. • Include dried beans (fava beans as stewed

Foul Medames and Falafel) and lentils in your meals.

• Include fish in your meals more often, in place of red meat.

• Choose lean cuts of beef and veal. Remove the skin from chicken and turkey.

• Choose low or non-fat dairy products such as skim milk, non-fat yogurt and low fat or non-fat cheese.

• Choose water and sugar-free, very low calorie beverages, rather than sugar sweetened beverages.

• Limit use of table salt and observe and evaluate use of food items containing so-dium.

• Limit the use of added fat when cooking. • Preferred methods of cooking are baking,

broiling , grilling and boiling,;limit con-sumption of fried food.

• Limit the portion size of foods eaten, to maintain a weight within recommended guidelines.

• Cut back on high calorie snack foods and desserts like chips, cookies, cakes, and full-fat ice cream.

Appendix 2Glycemic index and glycemic load

The glycemic index (GI) measures how a car-bohydrate-containing food raises blood glucose. Foods are ranked based on how they compare to a reference food– either glucose or white bread. A food with a high GI raises blood glucose more than a food with a medium or low GI. Examples of carbohydrate-containing foods with a low GI include dried beans and legumes (like beans and lentils), all non-starchy vegetables, most fruits and many whole grain breads and cereals. How-ever, GI, is not always true as it is affected by storage time, ripeness or food processing. Fat and fiber tend to lower the GI of a food. As a general rule, the more cooked or processed a food, the higher the GI; however, this is not always true. Portion sizes are still relevant for managing blood glucose and for losing or main-taining weight.

The glycemic index compares the potential of foods containing the same amount of carbo-hydrate to raise blood glucose. However, the amount of carbohydrate consumed also affects blood glucose levels and insulin responses. The glycemic load of a food is calculated by mul-tiplying the glycemic index by the amount of carbohydrate in grams provided by a food and dividing the total by 100. Dietary glycemic load is the sum of the glycemic loads for all foods consumed in the diet. The concept of glycemic load was developed by scientists to simultane-ously describe the quality (glycemic index) and quantity of carbohydrate in a meal or diet (33).

Appendix 3Carbohydrate Counting

Carbohydrate counting, or «carb counting,» is a technique for managing your blood glucose levels. Foods that contain carbohydrate raise blood glucose. By keeping track of how much carbohydrate you eat, and setting a limit for the maximum amount you will eat, you can help to keep your blood glucose levels in your target range. Finding the right amount of carbohydrate depends on many things including how active you are and what, if any, medicines you take.

How much carbohydrate?A place to start is at about 45-60 grams of carbohydrate at a meal. If snacks are de-sired, they should be limited to 15 to 30 grams carbohydrate. You may need more or less carbohydrate at meals depending on how you manage your diabetes. You and your health care team can figure out the right amount for you. Once you know how much carbohydrate to eat at a meal, choose your food and the portion size to match.

What foods have carbohydrate?Foods that contain carbohydrate are:

• Starchy foods like bread, cereal, rice, and crackers

• Fruit and juice • Milk and yogurt • Dried beans • Starchy vegetables like potatoes and

corn • Sweets and snack foods like sodas, juice

drinks, cake, cookies, candy, and chips

Non-starchy vegetables have a small amount of carbohydrate but in general are very low.

How much carbohydrate is in these foods?Reading food labels is a great way to know how much carbohydrate is in a food. For foods that do not have a label, you have to estimate how much carbohydrate is in it. Keeping general serving sizes in mind will help you estimate how much carbohydrate you are eating.

For example there is about 15 grams of carbo-hydrate in:

• 1 small piece of fresh fruit (4 oz) • 1/2 cup of canned or frozen fruit, un-

sweetened • 1/2 of the traditional piece of Egyptian

bread• 1/2 cup of oatmeal • 1/3 cup of pasta or rice • 1/2 cup of beans (Foul ) or starchy veg-

etable ( e.g. potato )

184 Volume 8, Number 4, 2009 • CLINICAL DIABETES (MIDDLE EAST EDITION)

L O C A L A R T I C L E S

• 2/3 cup of plain fat-free yogurt or sweet-ened with sugar substitutes

• 2 small cookies • 1/2 cup ice cream • 1 Tbsp syrup, jam, jelly, sugar or honey • 6 chicken nuggets • 1 cup of soup • 1/4 serving of a medium French fries

Protein and Fat With carbohydrate counting, it is easy to forget about the protein and fat in meals. Always in-clude a source of protein and fat to balance out your meal.

Appendix 4Using Food Labels

Carbohydrate counting is easier when food la-bels are available. You can look at how much carbohydrate is in the foods you want to eat and decide how much of the food you can eat. The most important information on a food label in relation to carbohydrate counting is the serving size, the total carbohydrate amount for serving and the number of servings in a container.

1. Look at the serving size. All the nutri-tion information on the label relates to one serving of food. If you will be eating a larger serving than this, then you will need to double or triple the information on the label.

2. Look at the grams of total carbohydrate. Total carbohydrate on the label includes sugar, starch, and fiber. Know the amount of carb you can eat, figure out the portion size to match. Refer to your meal plan and figure out the portion size you want to eat so it fits in your plan.

Other important label information:

3. If you are trying to lose weight, look at the calories. Comparing products can be helpful to find those lower in calories per serving.

4. To cut risk of heart disease and stroke, look at saturated and trans fats. Look for products with the lowest amount of satu-rated and trans fats per serving.

5. For people with high blood pressure, look at the sodium. Look for foods with less sodium.

AcknowledgmentThe Egyptian Diabetes Center with a support from Les Laboratories Servier made this work possible , we are grateful to the American Dia-betes Association

References:

1. Diabetes care, volume 32, supplement 1, January 2009 , S13 – 61.

2. Franz MJ, Bantle JP, Beebe CA, Brunzell , JD, Chiasson JL, Garg A, Holzmeister, LA, Hoogwerf B, Mayer-Davis E, Mooradian AD, Purnell JQ, Wheeler M: Evidence based nutrition principles and recommendations for the treatment and prevention of diabetes and related complications. Diabetes Care 25:148 –198, 2002.

3. IDF Diabetes Atlas 3rd edition, December 2006.

4. (Al-Nozha MM, Al-Mazrou YY, Al-Maa-touq MA, Arafah MR, Khalil MZ, Khan

NB, Al-Marzouki K, Abdullah MA, Al-Khadra AH, Al-Harthi SS, Al-Shahid MS, Al-Mobeireek A, Nouh MS. Obesity in Saudi Arabia. Saudi Med J. 2005 May; 26(5):824-9.

5. Jafar Muhammad El-Qudah. Food Con-sumption Patterns and Patterns and Preva-lence of Obesity in an Adult Population in Amman, Jordan. Australian Journal of Ba-sic and Applied Sciences, 2(4): 1165-1171, 2008.

6. Maleka Serour, Hanadi Alqhenaei, Sawsan Al-Saqabi, Abdel-Rahman Mustafa and Abdullah Ben-Nakhi. Cultural factors and patients’ adherence to lifestyle measures. British Journal of General Practice, April 2007.

7. Kuwait Nutrition Surveillance System, WHO/EMRO 2007.

8. Suhail Kishawi, unpublished report, Diabe-tes Mellitus in Palestine,2004.

9. A.O. Musaiger. Overweight and obesity in the Easter Mediterranean Region: can we control it? Eastern Mediterranean Health Journal. Vol. 10. No. 6, November 2004, 789-793 – A.O. Musaiger. Diet and preven-tion of coronary heart disease in the Arab Middle East countries. Medical Principals and Practice, 2002, 11(suppl. 2): 9-16.

10. Kuwait Nutrition Profile – Nutrition and Consumer Protection Division, FAO, 2006.

11. H. Hassan-Wassef. Food habits of the Egyp-tians: newly emerging trends. La Revue de Santé de la Méditerranée orientale, Vol. 10, No 6, 2004.

12. Pastors JG, Warshaw H, Daly A, Franz M, Kulkarni K: The evidence for the effective-ness of medical nutrition therapy in diabetes management. Diabetes Care 25:608–613, 2002.

13. Pastors JG, Franz MJ, Warshaw H, Daly A, Arnold MS: How effective is medical nutri-tion therapy in diabetes care? J Am Diet As-soc 103:827–831, 2003.

14. Yu-Poth S, Zhao G, Etherton T, Naglak M, Jonnalagadda S, Kris-Etherton PM: Effects of the National Cholesterol Education Pro-gram’s Step I and Step II dietary interven-tion programs on cardiovascular disease risk factors: a metaanalysis. Am J Clin Nutr 69:632– 646, 1999.

15. Grundy SM, Balady GJ, Criqui MH, Fletch-er G, Greenland P, Hiratzka LF, Houston-Miller N, Kris-Etherton P, Krumholz HM, LaRosa J, Ockene IS, Pearson TA, Reed J, Smith SC Jr, Washington R: When to start cholesterol-lowering therapy in patients with coronary heart disease: a statement for healthcare professionals from the American Heart Association Task Force on Risk Re-duction. Circulation 95:1683–1685, 1997.

16. Chobanian AV, Bakris GL, Black HR, Cush-man WC, Green LA, Izzo JL Jr, Jones DW, Materson BJ, Oparil S,Wright JT Jr, Roc-cella EJ: The Seventh Report of the Joint National Committee on Prevention, De-tection, Evaluation,and Treatment of High Blood Pressure: the JNC 7 report. JAMA 289:2560–2572, 2003.

17. Whitworth JA, Chalmers J: World Health Organisation–International Society of Hy-pertension (WHO/ISH) hypertension guide-lines. Clin Exp Hypertens 26:747–752, 2004.

18. National Heart, Lung, and Blood Institute: Clinical Guidelines on the Identification, Evaluation and Treatment of Overweight and Obesity in Adults. Bethesda, MD, Na-tional Institutes of Health, 1998.

19. Norris SL, Zhang X, Avenell A, Gregg E, Bowman B, Schmid CH, Lau J: Longterm

effectiveness of weight-loss interventions in adults with pre-diabetes: a review. Am J Prev Med 28:126 –139, 2005.

20. Nathan D , Buse J, Davidson M , Fer-rannini E , Holman R , Sherwin R, Zinman B Medical Management of Hyperglycemia in Type 2 Diabetes: A Consensus Algorithm for the Initiation and Adjustment of Thera-py . Diabetes care, volume 31, number 12, December 2008 , 1 – 11.

21. American Diabetes Clinical Practice Recom-mendations 2009 , Diabetes Care Supple-ment 1 , Volume 32 : S13 – S61.

22. Tuomilehto J, Lindstrom J, Eriksson JG, Valle TT, Hamalainen H, Ilanne-Parikka P, Keinanen-Kiukaanniemi S, Laakso M, Louheranta A, Rastas M, Salminen V, Uusitupa M: Prevention of type 2 diabe-tes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Engl J Med 344:1343–1350, 2001.

23. Knowler WC, Barrett-Connor E, Fowler SE, Hamman RF, Lachin JM, Walker EA, Nathan DM: Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 346: 393–403, 2002.

24. Mayer-Davis EJ, Sparks KC, Hirst K, Costacou T, Lovejoy JC, Regensteiner JG, Hoskin MA, Kriska AM, Bray GA: Dietary intake in the Diabetes Prevention Program cohort: baseline and 1-year post randomiza-tion. Ann Epidemiol 14: 763–772, 2004.

25. Frank M. Sacks, M.D., George A. Bray, M.D., Vincent J. Carey, Ph.D., Steven R. Smith, M.D., Donna H. Ryan, M.D., Stephen D. Anton, Ph.D., Katherine Mc-Manus, M.S., R.D., Catherine M. Cham-pagne, Ph.D., Louise M. Bishop, M.S., R.D., Nancy Laranjo, B.A., Meryl S. Leb-off, M.D., Jennifer C. Rood, Ph.D., Lilian de Jonge, Ph.D., Frank L. Greenway, M.D., Catherine M. Loria, Ph.D., Eva Obarzanek, Ph.D., and Donald A. Williamson, Ph.D : Comparison of Weight-Loss Diets with Different Compositions of Fat, Protein, and Carbohydrates, N Engl J Med 360:859-873,2009.

26. Sheard NF, Clark NG, Brand-Miller JC, Franz MJ, Pi-Sunyer FX, Mayer-Davis E, Kulkarni K, Geil P: Dietary carbohydrate (amount and type) in the prevention and management of diabetes: a statement of the American Diabetes Association. Diabetes Care 27:2266–2271, 2004.

27. Mayer-Davis EJ, Dhawan A, Liese AD, Teff K, Schulz M: Towards understanding of glycemic index and glycemic load in habit-ual diet: associations with measures of glyc-emic in the Insulin Resistance Atherosclero-sis Study. Br J Nutr 95:397– 405, 2006.

28. Salmeron J, Hu FB, Manson JE, Stampfer MJ, Colditz GA, Rimm EB, Willett WC: Dietary fat intake and risk of type 2 diabetes in women. Am J Clin Nutr 73: 1019–1026, 2001.

29. Rabasa-Lhoret R, Garon J, Langelier H, Poisson D, Chiasson JL: Effects of meal carbohydrate content on insulin require-ments in type 1 diabetic patients treated intensively with the basal-bolus (ultralente regular) insulin regimen. Diabetes Care 22:667– 673, 1999.

30. Crowther CA, Hiller JE, Moss JR, McPhee AJ, Jeffries WS, Robinson JS: Effect of treatment of gestational diabetes mellitus on pregnancy outcomes. N Engl J Med 352:2477–2486, 2005.

31. Liu S, Willett WC. Dietary glycemic load and atherothrombotic risk. Curr Atheroscler Rep. 2002;4(6):454-461

CLINICALDIABETESME.ONLINEDIABETES.NET

82009

2009