2) Herewith the 2nd question in our Q&A series with Ria Catsicas about 'Nutrition and Diabetes':

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1 DIABETES Q&A WITH RIA CATSICAS 1) Today is World Diabetes Day! We ve been chatting to clinical dietitian and nutrition consultant Ria Catsicas about nutrition and diabetes. Ria is a specialist in the practice of nutrition management in diabetes, metabolic syndrome and obesity and has authored the book The Complete Nutritional Solutions to Diabetes. Starting today, for the next eight days, we will be posting her answers to our questions. If you have any questions for Ria, please post them and we will endeavour to get them answered: HOW DOES OBESITY CONTRIBUTE TO THE DEVELOPMENT OF DIABETES? Urbanisation has resulted in South Africa following the global trend of an escalating prevalence of obesity with a consequential increase in the development of Type 2 diabetes. 90% of the prevalence of Type 2 diabetes is related to obesity with special reference to abdominal obesity. According to the recently published South African National Health and Nutrition Examination Survey (SAHANES-1) 20% of men in the age groups years are obese and 55% in the age group of years. Abdominal obesity appears to be a dominant. 22% of men between years of age and 70% of women between years have a waist circumference exceeding the guidelines as proposed by the WHO (2011) of 102 cm for men and 88 cm for women. It is important to note that the prevalence of impaired glucose intolerance appeared to be 16.7% in the age group and as high as 24.4% for the age group years. Abdominal fat cells release substances that make most body cells resistant to the action of insulin. Consequently the pancreas has to work harder producing more insulin to overcome the resistance. With time the cells producing insulin die off due to exhaustion, which together with too much sugar and fat in the diet affects their capacity. As a result the insulin produced become less. If eventually the amount of insulin produced is too little to overcome the cell resistance, the glucose (from food) stays in the blood and Type 2 diabetes is diagnosed. The process that precedes diagnosis (Insulin resistance) is called pre-diabetes. A great concern is that Type 2 diabetes can be asymptomatic for a period of time and it is suspected that a large number of individuals have undiagnosed Type 2 diabetes. 2) Herewith the 2nd question in our Q&A series with Ria Catsicas about 'Nutrition and Diabetes': WHAT IS THE ROLE OF NUTRITION IN RELATION TO DIABETES? The food that we eat is digested and provides our body with a variety of nutrients and energy measured in kilojoules. Carbohydrate foods are broken down into glucose, which is the main source of energy for our bodies. Proteins are broken down into amino acids, which are needed for growth and repair of the body. Fats are broken down into triglycerides, which are used for energy and a variety of functions within the body for example hormone production and for keeping cell membranes healthy. Following the digestion of food, glucose (from carbohydrates) is absorbed from the small intestine

2 into the blood stream. In response to the increased blood glucose levels, the pancreas releases insulin into the blood stream to assist with transporting the glucose into the cell. This causes the blood glucose levels drop to normal levels again, and so the process repeats itself after each meal. The rise in your blood glucose levels is determined by the amount of glucose entering the blood stream. This depends on the rate of digestion of the food and amount of food eaten, as well as the rate of clearance from the blood into the body s cells, via insulin. In people with diabetes the amount of insulin released is inadequate and clearance of glucose into the cells is significantly delayed. The THREE basic nutrition components that affect your blood glucose levels on a daily basis are: 1. The timing of your meals and snacks. 2. The quantity of foods and drinks you consume daily 3. The types of foods and drinks you consume daily. 3) Hope you had a wonderful weekend! We start the week with the 3rd question in our Q&A series with clinical dietitian and nutrition consultant Ria Catsicas: HOW DOES THE TIMING OF MEALS AND SNACK AFFECT BLOOD GLUCOSE LEVELS? The current generation of insulin and other diabetes medications give people with diabetes flexibility with regard to the timing of meals and snacks. However, it is still recommended that you eat three regular meals per day. This offers the best way to control the size of your meals, and thus your blood glucose and energy levels throughout the day. Regularly skipping meals can cause your blood glucose levels to drop too low. This may cause you to compensate by overeating at the next meal, or needing to snack inappropriately between meals. Depending on the size of your meals, the type of medication you use, your lifestyle and appetite, you can enjoy snacks between meals. Snacking is recommended if the meals are more than 5 to 6 hours apart. When you are overweight be aware not to snack inappropriately due out of the power of habit and the visibility and availability of food. Join us again tomorrow for Ria's response to: HOW DOES THE QUANTITY OF FOODS AND DRINKS AFFECT YOUR BLOOG GLUCOSE LEVEL? 4) Today Ria Catsicas responds to the 4th question in our diabetes Q&A series: HOW DOES THE QUANTITY OF FOODS AND DRINKS AFFECT YOUR BLOOD GLUCOSE LEVEL?

3 The quantity of foods (portion sizes) you should eat is individual and varies from person to person. The factors that play a role in determining what portions you should eat depends on your weight status, activity levels, the type of medication you use, your gender, age and level of glycaemic control (blood sugar control). The best way to gain knowledge on how many portions you need to consume of the different foods on a daily basis is to consult a registered dietician, who can calculate a practical nutritionally balanced eating plan taking your lifestyle as well as the above mentioned factors in consideration. If you are following an insulin regime of injecting before each meal (basal bolus) you can learn to adjust the amount of insulin you need to inject for a meal according to the amount of carbohydrate you plan to enjoy in a meal. This is called carbohydrate counting. You need to learn the amount of carbohydrate all foods contain and develop your own carbohydrate: insulin ratio. As this can provide you with more flexibility towards the size and composition of your meals, it needs to be done under the supervision of a registered dietician. 5) Today as part of our Diabetes Q&A we are talking carbs and glucose levels with Ria Catsicas: HOW ARE GLUCOSE LEVELS AFFECTED BY THE CARBOHYDRATES WE CONSUME? The consumption of different types of carbohydrate foods affects our blood glucose levels in different ways. We classify carbohydrate foods on how they affect people s blood glucose levels using the Glyceamic Index (GI). The fibre in whole grains, fresh fruit and vegetables delays digestion and causes the slow release of glucose into the blood stream that is beneficial. High fibre foods usually have a low GI value. The milling of grains removes the fibre from the grains and produce white flour. This also happens when we remove the fibre from fresh fruit when making fruit juices. Low fibre foods have a high GI value as they are more rapidly digested and glucose is faster absorbed into the blood stream causing higher blood glucose levels. Including low GI carbohydrates usually high in fibre to the expense of high GI starches usually low in fibre (made from white flour) is recommended. This contributes to improved blood glucose control and consequent improved appetite and weight control. Examples of these foods are: whole grains such as rolled oats, barley, brown wild rice, bulgur wheat, pearl wheat (stamp koring) quinoa, health / rye breads, legumes (lentils, dry beans, chick peas). They not only contain fibre but additional nutrients important for lowering cholesterol and managing weight loss. Key points to remember when selecting carbohydrate foods for your daily eating plan: 1.Aim for a minimum of five portions of fresh fruit and vegetables per day, as they all have a low GL and are high in fiber. 2.Select high-fiber /low-gi starches and limit your intake of refined starches (those with a high flour and sugar content) such as all brown, white and whole wheat breads and rolls, maize pap, all bakery items such as vetkoek, chelsea buns, pies, cakes, biscuits, salty crackers oven baked chips, and take out foods such as burgers and chips, pizzas, prego rolls, tramizini s, wraps, rotis naan bread, sweets, chocolates, all sugar based cold drink, fresh fruit juices vitamin and flavored waters. 3.Eat one to two portions of whole grains each day.

4 4.Control your portions. The quantity of carbohydrate foods you eat affects your blood glucose levels. 5.Fresh fruit is the best snack to enjoy. 6) Our 6th question in the diabetes Q&A series, focuses on protein: HOW ARE GLUCOSE LEVELS AFFECTED BY THE PROTEIN WE CONSUME? As protein foods contain fats the main objective is to select lean protein foods to lower the total saturated fat content of the diet. Including proteins into the diet enables you to keep the quantity of starches that enhance glycemic control small. Dried beans, peas and lentils are not only low-fat sources of protein, but also contain soluble fibre that has a cholesterol-lowering effect. Replacing some animal proteins with legumes can help to lower your intake of saturated fats. The high soluble-fibre content in legumes is also responsible for a slower digestion and absorption of carbohydrates, which contributes to an improved blood glucose response after a meal. As white fish contains significant less saturated fat as red meat and fatty fish contains essential fats with health benefits make fish is an excellent protein source to include into your diet. Find tasty innovative ways to prepare fish. Key points to remember about proteins: 1.Lower your intake of saturated fats by avoiding protein and dairy foods that are high in saturated fats such as fatty meats, processed meats and hard cheeses. 2.Select all low fat milk and milk products and low fat cheese. Lean protein total fat content is less than 10 g fat / 100 g food. 3.Use skin less chicken when using stir frying and stewing as cooking methods. Remove the skin afterwards when roasting chicken in the oven or on the coals. 4.Eating protein enables you to consume smaller portion of starch, which will improve your glycaemic control. 5.A small amount of protein is sufficient to sustain our body s growth and metabolic processes. 6.Choose lean proteins, such as fatty fish, white fish, legumes, lean meat and chicken, eggs, low-fat soft cheeses and hard cheese. 7) We are nearing the end of our diabetes and nutrition Q&A series for Ria Catsicas. Today we look at how fats affect glucose levels: HOW ARE GLUCOSE LEVELS AFFECTED BY THE FATS WE CONSUME? Fats play an essential role in your diet and support many metabolic functions in the body. The fats that increase blood cholesterol levels and decrease the insulin sensitivity of the cells originate from animal sources. These fats are solid at room temperature and are saturated in nature. Unsaturated fats from plant origin especially mono unsaturated fats do not increase cholesterol, keeps your cells healthy and sensitive to insulin. It is recommended that you replace all saturated fats in your diet

5 with unsaturated fats. Transfats are a type of fat the food industry sometimes use when manufacturing baking items and is also found in fast foods. Transfats have the same unhealthy qualities as saturated fats and should be avoided. All types of fats are calorie dense and can contribute to weight increase if consumed without discretion. It is thus important to control the amounts of healthy fats included into your daily diet. The essential fatty acids we found in fatty fish such as sardines, pilchards, mackerel and salmon have numerous health benefits that protect you against heart disease. It is recommended that you include a minimum of three portions of fatty fish per week into your diet. Key points to remember when selecting fats for your daily eating plan: 1.Limit your intake of saturated and trans-fats and choose unsaturated fats when possible. 2.Oleic acid (a monounsaturated fat found in olive oil, canola oil, avocados and some nuts) has superior health benefits and should be the oil of choice in our diet. 3.Avoid exceptionally low-fat diets, as your body needs a certain amount of healthy fats to enable it to function normally. 4.Eat fatty fish at least three times a week for the beneficial effects of Omega 3 fatty acids. 5.Control the quantity of all fats in your daily eating plan, as all fats are calorie dense and will add weight. 8) The last question in our diabetes Q&A with Ria Catsicas, looks at sugar and sweeteners: WHAT ABOUT DIABETES AND SUGAR / SWEETENERS? We all like a bit of sweetness in our diets. Some people with diabetes try to avoid every gram of sugar, scrutinizing labels for the term sugar, while others happily drink one to two glasses of sugarsweetened cold drinks per day, equating to as much as 70 g (14 teaspoons) of sugar. Sweeteners can be classified into two categories: nutritive and non-nutritive or artificial sweeteners. The difference between them is that nutritive sweeteners contain calories while non-nutritive sweeteners contain none. There are numerous types of sweeteners and often claims are made that artificial sweeteners cause diseases such as cancer. Nutritive sweeteners Apart from cane sugar, other nutritive sweeteners are honey, glucose, fructose, maltose, maltodextrin and lactose (milk sugar). All these sweeteners contain the same amount of calories as sugar. Sucrose (cane sugar) the way sucrose influences your blood glucose levels depends on the amount of sugar used and how it is used. For example, consuming a 50g chocolate bar that contains 30g (6 teaspoons) of sugar or a 340ml cold drink that contains 35g (7 teaspoons) between meals will affect your blood glucose levels more significantly profoundly than using a few teaspoons of sugar as part of a sauce for a chicken dish that is eaten with brown rice and vegetables (thus in the context of a high-fibre meal). A small amount can be used in food preparation. The sucrose that occurs in commercial foods is

6 normally eaten as part of a high-fibre meal anyway (such as baked beans on whole wheat toast or in bran cereals). When sucrose and free fructose are used in large quantities, such as in cold drinks, fruit juices, sweets or chocolates or combined with white flour in bakery items, you need to control the quantity and frequency of consumption. This is especially true if you need to lose weight and your blood glucose control is not ideal. Enjoy these foods very sporadically in the context of social events, such as a birthday party. Replace the use of sugar in tea and coffee with artificial sweeteners and use sugar free cold drinks in place of sugar based drinks, flavoured water, vitamin water and all types of fruit juices. Non-nutritive sweeteners These sweeteners have an intense, sweet taste and are used in minute quantities. They are normally mixed with a bulking agent into a powder or tablet form and called by their chemical names: Aspartame, Ascelfame K, sucralose or saccharine. If you use non-nutritive sweeteners, it is advisable to use a variety of different sweeteners and use them in moderation (no more than 3-6 sachets or tablets a day). Diet cold drinks contain a significant amount of artificial sweetener and should be enjoyed sporadically, with a maximum of 3 to 4 a week. Water is the best drink for hydration. Try to get into the habit of drinking all your other beverages without sweetener.

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