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INTRODUCTION
Health is a fundamental human right and a worldwide social goal. It encompasses
all humans disregard of age. Geographical conditions, culture, economic status and
lifestyle of people have foremost impact on their health. Chronic diseases account for a
large proportion of the global burden of disease and are the major cause of death in
almost all countries. It is estimated that diabetes, cardiovascular disease, cancer and other
chronic, non-communicable diseases caused 35 million deaths in 2005. Poor food habits
and sedentary hedonistic lifestyle have resulted in the perpetuation of diseases like
obesity and diabetes mellitus. In which Diabetes presents major challenges to patients,
health systems and national economies. The World Health Organization together with the
International Diabetes Federation is working to raise awareness of diabetes worldwide
along with improving the quality of care. (Diabetes Atlas, IIIEd., 2006).
Global diabetes prevalence has more than doubled over the last three decades,
with prevalence rates far exceeding modeled projections, even after allowing for
improved surveillance. Nearly 1 in 10 adults worldwide are now affected by diabetes
(Danaei et al., 2011).Diabetes presents major challenges to patients, health systems and
national economies. The World Health Organization together with the International
Diabetes Federation is working to raise awareness of diabetes worldwide along with
improving the quality of care.
History of Diabetes:
The Hindu physicians, Charak and Sushrut, who wrote between 400 and 500
BC, were probably the first to recognize the sweetness of diabetic urine. Indeed, the
diagnosis was made by tasting the urine or noting that ants congregated round it. Charak
and Sushrut noted that the disease was most prevalent in those who were indolent,
overweight and gluttonous, and who indulged in sweet and fatty foods. Physical exercise
and liberal quantities of vegetables were the mainstays of treatment in the obese, while
lean people, in whom the disease was regarded as more serious, were given a nourishing
diet. The crucial fact that diabetic urine tasted sweet was also emphasized by Arabic
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medical texts from the 9–11th centuries AD, notably in the medical encyclopaedia
written by Avicenna (980 – 1037).
Sushrut (Susrata), an Indian physician who wrote medical texts with Charak (Charuka)
between 500 BC and 400 BC
Diabetes mellitus is a disease of antiquity. A treatment was described in the Ebers
papyrus and as long ago as 600 BC two main types were distinguished. Perhaps the most
famous description was by Arateus the Cappadocian who talked of the melting down of
flesh into urine and of the end being speedy. Over the ensuing centuries sporadic
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descriptions were noted, with Maimonides in Egypt pointing out its relative rarity. It was
attributed to a salt - losing state although the sweetness of the urine had long been known.
Undoubtedly, virtually all of these accounts referred to type 1 (T1DM) or late type 2
diabetes (T2DM). Diabetes was better recognized in the 17th and 18th centuries, with the
association with obesity noted in some cases. The obvious breakthrough came in the 17th
century with the demonstration of excess glucose in the urine and later also in blood. The
presence of excess ketones was shown in the 19th century.
A clear description of the two main types of diabetes appeared at the end of the
19th century, with the distinction being made between that occurring in young people
with a short time course before ketoacidosis supervened, and that found in older people
who were obese. Over the next decades these became known as juvenile - onset diabetes
and maturity - onset diabetes, although it was generally stated that the latter was just a
milder form of the disease. Diagnosis now depended on glucose measurement with some
using glucose tolerance tests. There were no standard criteria for these initially, although
glucose levels were clearly above normal. Diagnosis usually occurred after clinical
development of the disease with the combination of symptoms with raised glucose in the
blood or glycosuria being diagnostic, together with ketonuria in the juvenile - onset form.
A further breakthrough occurred with the work of Himsworth in 1936.
Himsworth’s work showed that people with diabetes could be divided into insulin resistant and insulin - sensitive types, with the former much more common in those with
the maturity - onset variety (Himsworth HP. Et.al, 1936). The next milestone was the
development of the radioimmunoassay for insulin which allowed the unequivocal
demonstration of insulin deficiency, or indeed absence, in those with juvenile - onset
diabetes while levels were apparently normal or raised in those with maturity - onset
diabetes. At that time, diabetes was still considered to be a relatively uncommon disorder
occurring predominantly in Europids. The World Health Organization (WHO) began to
take note and held its first Expert Committee meeting in 1964 (World Health
Organization, 1964). The real breakthrough, however, in terms of diagnosis and
classification came in 1980 with the publication of the second Expert Committee report
(World Health Organization, 1980) shortly after the report from the National Diabetes
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Data Group (NDDG) in the USA in 1979 (National Diabetes Data Group, 1979). These
events form the starting point for the diagnostic criteria and classification used today.
TYPE-2 DIABETES AN EPIDEMIC FACED IN INDIA:
Diabetes is now one of the most common non-communicable diseases globally. It
is the fourth or fifth leading cause of death in most developed countries and there is
substantial evidence that it is epidemic in many developing and newly industrialized
nations. Complications from diabetes, such as coronary artery and peripheral vascular
disease, stroke, diabetic neuropathy, amputations, renal failure and blindness are resulting
in increasing disability, reduced life expectancy and enormous health costs for virtually
every society.
Diabetes is on increase in India. The multicenter ICMR study showed a
prevalence of 2.5% in the urban and 1.8% in the rural population above the age of 15
years. One in every eight individuals in India is a diabetic. The revised WHO figures for
the years 2025 is 57.2 million diabetics in India. The average age for the onset of diabetes
in India is around 40 years while it is around 55 years in other countries (Srilakshmi,
2005).
With India having the highest number of diabetic patients in the world, the sugar
disease is posing an enormous health problem in the country. Calling India the diabetes
capital of the world,. The World Health Organization estimates that mortality from
diabetes and heart disease cost India about $210 billion every year and is expected to
increase to $335 billion in the next ten years. These estimates are based on lost
productivity, resulting primarily from premature death (SaikatNeogi, Hindustan Times,
2007).
The prevalence of diabetes is rising all over the world due to population growth,
aging, urbanisation and an increase of obesity and physical inactivity. Unlike in the West,
where older persons are most affected, diabetes in Asian countries is disproportionately
high in young to middle-aged adults. This could have long-lasting adverse effects on a
nation’s health and economy, especially for developing countries. The International
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Diabetes Federation (IDF) estimates the total number of people in India with diabetes to
be around 50.8 million in 2010, rising to 87.0 million by 2030 ( Ramachandran,2010)
According to the ICMR – INDIAB study, there are 62.4 million people living with
diabetes in India. Type 2 diabetes (T2DM) is a progressive disease and hampers the
quality of life of the patients due to micro and macrovascular complications. There are
few studies on the status of glycemic control in the country. Such data would be useful to
allocate health resources and plan measures for instituting better control of diabetes.
Glycemic control in India is poor and this has resulted in a high prevalence of
complications. This emphasizes the fact that effective control of T2DM is urgently
needed to prevent or reduce the risk of developing the complications of diabetes in Indian
T2DM patients (Viswanathan Mohan2013)
CLASSIFICATION OF DIABETES:
Diabetes mellitus is classified on the basis of aetiology and clinical presentation
of the disorder into following types:
1. Type-1 diabetes
Type 1 diabetes mellitus is characterized by loss of the insulin-producing beta
cells of the islets of Langerhans in the pancreas leading to insulin insufficiency. This type
of diabetes can be further classified as immune-mediated or idiopathic. The majority of
type 1 diabetes is of the immune-mediated nature, where beta cell loss is a T-cell
mediated autoimmune attack (Rother K.I. 2007).
There is no known precautionary measure against type 1 diabetes, which causes
approximately 10% of diabetes mellitus cases in North America and Europe. Most
affected people are otherwise healthy and of a healthy weight when onset occurs.
Sensitivity and responsiveness to insulin are usually normal, especially in the early
stages. Type 1 diabetes can affect children or adults but was conventionally termed
"juvenile diabetes" because it represents a mainstream of the diabetes cases in children
(Diabetes Mellitus, 2010)
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2. Type-2 diabetes
Type-2 diabetes mellitus is characterized by insulin resistance which may be
pooled with relatively reduced insulin secretion (i.e. patients secrete insulin, but not
enough to overcome the insulin resistance). Typically, they do not require insulin to
survive but often will eventually need insulin to maintain reasonable glycaemia control,
often after many years.
The defective receptiveness of body tissues to insulin is supposed to involve the
insulin receptor. Type 2 diabetes is the most widespread nature. In the early stage of
type 2 diabetes, the main irregularity is reduced insulin sensitivity. At this stage
hyperglycaemia can be reversed by a range of measures and medications that improve
insulin sensitivity or reduce glucose production by the liver (David G. Gardner, 2011).
3. Gestational diabetes
Gestational diabetes mellitus (GDM) is a carbohydrate intolerance of varying
degrees of severity which starts or is first recognized during pregnancy. The definition
applies regardless of whether insulin is used for treatment or if the condition persists after
pregnancy. It does not exclude the possibility that unrecognized glucose intolerance may
have antedated the pregnancy.
Gestational diabetes mellitus (GDM) resembles type -2 diabetes in quite a lot of
respects, concerning a combination of relatively not enough insulin secretion and
sensitivity. It occurs in about 2%–5% of all pregnancies and may recover or vanish after
delivery. About 20%–50% of affected women develop type 2 diabetes afterward in life
(reference)
Even though it may be transient, untreated gestational diabetes can harm the
wellbeing of the foetus or mother. Risks to the baby include macrosomia (high birth
weight), congenital cardiac and central nervous system anomalies, and skeletal muscle
malformations.
A study completed in the U.S. in 2008 found that the number of American women
entering pregnancy with pre-existing diabetes is increasing. In fact the rate of diabetes in
expectant mothers has more than doubled in the past 6 years. This is particularly
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problematic as diabetes raises the risk of complications during pregnancy, as well as
increasing the potential that the children of diabetic mothers will also become diabetic in
the future (Lawrence JM, et.al. 2008).
Type 1 Diabetes
Results from the
body’s failure to
produce insulin
and presently
requires the person
to inject insulin
Type 2 Diabetes
Results when the
pancreas does not
produce enough to
control glucose
levels, or the cells
not responding to
insulin
Gestational Diabetes
Results when the body of a
pregnant women does not
secret excess insulin
required during pregnancy
leading to increased blood
sugar levels
Types of Diabetes
Types of Diabetes
SYMPTOMS AND COMPLICATIONS OF DIABETES:
Diabetes is a group of metabolic diseases characterized by hyperglycemia resulting from
defects in insulin secretion, insulin action, or both. The chronic hyperglycemia of
diabetes is associated with long-term damage, dysfunction, and failure of different
organs, especially the eyes, kidneys, nerves, heart, and blood vessels.
Several pathogenic processes are involved in the development of diabetes. These range
from autoimmune destruction of the β-cells of the pancreas with consequent insulin
deficiency to abnormalities that result in resistance to insulin action. The basis of the
abnormalities in carbohydrate, fat, and protein metabolism in diabetes is deficient action
of insulin on target tissues. Deficient insulin action results from inadequate insulin
secretion and/or diminished tissue responses to insulin at one or more points in the
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complex pathways of hormone action. Impairment of insulin secretion and defects in
insulin action frequently coexist in the same patient, and it is often unclear which
abnormality, if either alone, is the primary cause of the hyperglycemia.
Symptoms of marked hyperglycemia include polyuria, polydipsia, weight loss,
sometimes with polyphagia, and blurred vision. Impairment of growth and susceptibility
to certain infections may also accompany chronic hyperglycemia. Acute, life-threatening
consequences of uncontrolled diabetes are hyperglycemia with ketoacidosis or the
nonketotic hyperosmolar syndrome.
Long-term complications of diabetes include retinopathy with potential loss of vision;
nephropathy leading to renal failure; peripheral neuropathy with risk of foot ulcers,
amputations, and Charcot joints; and autonomic neuropathy causing gastrointestinal,
genitourinary, and cardiovascular symptoms and sexual dysfunction. Patients with
diabetes have an increased incidence of atherosclerotic cardiovascular, peripheral arterial
and cerebrovascular disease. Hypertension and abnormalities of lipoprotein metabolism
are often found in people with diabetes. (ADA,2012)
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CAUSES OR RISK FACTORS OF DIABETES
Type-2 diabetes has strong genetic links, meaning that type 2 diabetes tends to run
in families. Several genes have been identified and more are under study which may
relate to the causes of type-2 diabetes. Type 2 diabetes is often, but not always, associated
with obesity, which itself can cause insulin resistance and lead to elevated blood sugar
levels. It is strongly familial, but major susceptibility genes have not yet been identified.
There are several possible factors in the development of type 2 diabetes. Several risk
factors are known to be associated with increased risk of T2DM.
These include increasing age, obesity (especially central obesity), dietary excess,
dietary factors such as increased intake of animal fats, carbonated drinks, sedentary
lifestyle, a positive family history, history of gestational diabetes, polycystic ovary
syndrome, severe mental illness, presence of hypertension, hyperlipidemia or
cardiometabolic risk factors. The clustering of some of these risk factors – hypertension,
elevated blood glucose, elevated triglyceride, low high - density lipoprotein (HDL)
cholesterol, and abdominal obesity – is termed the metabolic syndrome. Many of these
risk factors are associated with a westernized lifestyle and increase with urbanization and
mechanization. The recognition of the role of these factors in the pathogenesis of T2DM
has led to recommendations for selective screening for T2DM in subjects with these risk
factors (Diabetes Care 2004).
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Dyslipidemia
Type 2
Diabetes
Risk factors in the development of Type 2 diabetes.
HDL (High Density Lipoprotein Cholesterol)
PCOS (Polycystic Ovarian Syndrome)
TG (Triglycerides)
Obesity accounts for 80 – 85% of the overall risk of developing T2DM, and
underlies the current global spread of the disease (Ma R, Chan J et.al. 2009). The risk of
T2DM increases as body mass index (BMI) increases above 24 kg/m 2 , although the risk
appears to be present in association with lower BMI cut - offs in Asians (WHO Expert
Consultation.2004,Ramachandran A et.al.,2009). While central obesity is a
particularly strong factor, it can impart further risk regardless of the overall level of
general obesity.
Epidemiologic studies have suggested that early life events such as low birth
weight and fetal malnutrition may also be associated with increased risk of diabetes and
cardiovascular disease later in life (Gluckman PD, et.al., 2008).
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Recent emerging risk factors of diabetes:
Decreased sleep:
In addition to changes in diet and level of physical activity, it is recently
recognized that short sleep duration, another facet of our modern lifestyle may also be an
important contributing factor to the increasing prevalence of T2DM. Early seminal work
has highlighted the detrimental effects of sleep deprivation on glucose tolerance and
insulin sensitivity (Spiegel K et.al., 1999). Subsequent cross – sectional studies have
suggested an association between short sleep duration and diabetes (Gottlieb DJ,et.al.,
2005) and obesity (KoGT,et.al., 2007).The exact mechanism whereby sleep restriction
increases diabetes risk is not clear, although it may be related to activation of the
sympathetic nervous system, decrease in cerebral glucose utilization, changes in the
hypothalamic
-
pituitary-adrenal
axis
as
well
as
other
neuroendocrine
dysregulation(Gangwisch JE, et.al., 2007).
Drug - induced metabolic changes:
There is increasing recognition that some commonly used medications may be
associated with adverse metabolic effects and increased risk of diabetes (Ma RC,et.al.,
2007). High dose thiazide diuretics are known to worsen insulin resistance and beta blockers can impair insulin secretion. More recently, the uses of antipsychotic agents,
particularly second generation (atypical) antipsychotics, have been linked with
hyperglycemia and diabetes (Buchholz Set.al., 2008).
Environmental pollutants:
While most studies on the increasing burden of diabetes with westernized lifestyle
have focused on changes in dietary patterns and the increasingly sedentary lifestyles,
recent studies suggest environmental pollutants may represent a previously unrecognized
link between urbanization and diabetes (Jones OA, et.al. 2008, Lee DH ,et.al., 2008) . For
example, there is strong cross - sectional association between serum concentrations of
chlorinated persistent organic pollutants with diabetes (Lee DH, et.al, 2006), as well as
components of the metabolic syndrome (Lee DH,et.al., 2007).
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ROLE OF DIET IN MANAGEMENT OF DIABETES:
Nutrition is a critical part of diabetes care. Balancing the right amount of
carbohydrates, fat, protein along with fiber, vitamins and minerals helps us to maintain a
healthy diet and a healthy lifestyle. Diet plays a central role in the management of
diabetes. Presently composition of the diet has changed considerably compared to olden
times and recommendations are now in line with those for a healthy diet for the general
population. Food choice and food habits are important aspects of management of T2DM
(Mcdowell, 2007).
Medical Nutrition Therapy in Diabetes (MNT):
Medical Nutrition Therapy (MNT) is a cornerstone of diabetes management. Medical
nutrition therapy is a self-management therapy. Education, support, and follow-up are
required to assist the diabetics to make lifestyle changes essential to successful nutrition
therapy. MNT is defined as “nutritional diagnostic, therapy, and counseling services for
the purpose of disease management, which are furnished by a registered dietitian or
nutrition professional”(U.S. Department of Health and Human Services, 2001).It plays
a critical role in managing diabetes and reducing the potential complications related to
poor glycemic ststus, lipid, and blood pressure. The objective of MNT is to help people
with diabetes learn how to make appropriate food choices that will have a positive impact
on metabolic abnormalities .Once made, these choice can help people with diabetes,
achieve optimum metabolic control that may delay or prevent diabetes related
complications and improve overall health control (ADA, 2008).
Medical nutrition therapy factors reviewed are carbohydrate intake (sucrose, nonnutritive sweeteners, glycemic index, and fiber), protein intake, cardiovascular disease,
and weight management. Contributing factors to nutrition therapy reviewed are physical
activity and glucose monitoring. Based on individualized nutrition therapy client/patient
goals and lifestyle changes the client/patient is willing and able to make, registered
dietitians can select appropriate interventions based on key recommendations that include
consistency in day-to-day carbohydrate intake, adjusting insulin doses to match
carbohydrate intake, substitution of sucrose-containing foods, usual protein intake,
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cardioprotective nutrition interventions, weight management strategies, regular physical
activity, and use of self-monitored blood glucose data. The evidence is strong that
medical nutrition therapy provided by registered dietitians is an effective and essential
therapy in the management of diabetes (Franz,2010)
Besides being skilled and knowledgeable in regard to assessing and implementing MNT,
nutrition counselors /dietitians must also be aware of expected outcomes from nutrition
therapy, when to assess outcomes, and what feedback, including recommendations,
should be given to referral sources. Research supports MNT as an effective therapy in
reaching diabetes treatment goals. Outcomes of several studies demonstrate that MNT
provided by a registered dietitian (RD) is associated with a decrease of about 1.0% of
A1C in patients with newly diagnosed type 1 diabetes (Kulkarni et al, 1998), a decrease
of about 2.0%of A1C in patients with newly diagnosed type 2 diabetes (Franz et al,
1995; UKPDS Group, 1990), and a decrease of about 1.0% of A1C in patients with an
average 4-year duration of type 2 diabetes (Franz etal, 1995). These outcomes are similar
to those from oral glucose-lowering medications. Furthermore, the effect of MNT on
A1C will be known by 6 weeks to 3 months, at which time the RD/nutrition counselor
must assess whether the goals of therapy have been met by changes in lifestyle and
whether changes or additions of medications are needed (ADA, 2001).
Diabetic diet need not be a deviation from the normal diet. The nutritional
requirements of a diabetic are the same as in the nondiabetic.Normal Indian diets are
generally high in carbohydrate and low in fat, with carbohydrates providing 60-65% and
fat providing 15-25% of total calories. The rest is derived from proteins. Thus, even a
normal Indian diet is ideal for a diabetic. However, the nutrient intake has to be tailor
made to the individual based on the age, sex, weight, height, physical activity and
physiological needs of the patients (Raghurametal., 2008)
The ability to achieve optimal glycemic control in diabetes management is highly
influenced by food intake. The initial focus for nutrition education messages is to aim for
consistency in both type and quantity of carbohydrates consumed. However, research in
the past decade has acknowledged that not all carbohydrates effect blood glucose levels
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in the same way. One of the methods for evaluating this effect is known as the glycemic
index (GI)(Amanda et al., 2011).
The American Diabetes Association's standards of care recommend that the use of
the Glycemic Index (GI) and Glycemic Load (GL) may provide a modest additional
benefit for glycemic control(ADA, 2011). The GI indicates the rate at which food enters
the bloodstream. Therefore, foods with lower GI enter at a slower rate, which reduces
both the glycemic response and the corresponding insulin release. There is a positive
correlation between consumption of high-GI foods and an increases incidence of type 2
diabetes (Opperman et al., 2004).Decreasing the GI of the diet may improve insulin
sensitivity, reducing the risk for disease.
The GI is a ranking system that indicates how quickly a carbohydrate food raises
blood glucose. This is determined by measuring the area under the curve in the 2 hours
after the consumption of a test food. These values are then compared to the area under the
curve 2 hours after the consumption of a similar weight of glucose or bread (Amanda et
al., 2011).Foods ranked ≤ 55 are considered to have a low GI. Low-GI foods include
many fruits and vegetables, legumes, whole grains, and dairy products. Foods with a
ranking between 56-69 are considered to have a moderate GI. High-GI foods, those with
a ranking between ≥70 (Foster et al., 2002)
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Dietary fiber is the non-digestible component of complex carbohydrates and
promotes beneficial physiological effects such as laxation, reduction in blood cholesterol
and postprandial blood glucose modulation. It has been studied in the treatment of
diabetes for many years because increased fiber content decreases GI of the foods (Babio
et al, 2010 & Post et al , 2012).Several beneficial effects of low-GI, high-fiber diets have
been shown, including lower postprandial glucose and insulin responses, an improved
lipid profile, and, possibly, reduced insulin resistance (Gabriele et al., 2008). A recent
prospective cohort study has stated that the Low Glycemic index (GI) foods have
beneficial effects in control of hyperglycemia especially in type 2 diabetes mellitus where
first phase insulin secretion by beta cells of pancreas is defective. Substantially reducing
high GI starchy rice and wheat preparation in daily diet and replacing them by low GI
and popular Bengal gram and pulses as staples, helped ensure satiety and adequate
calories (Ghosh et al., 2005)
DIABTES FOOD PYRAMID
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The main aim of diet therapy is to help persons with diabetes in making
appropriate changes in their lifestyle both in their diet and exercise habits, which would
lead to improved metabolic control. The diet should help reduce symptoms of diabetes
by keeping blood sugar, lipids, blood pressure and body weight under control.
PURPOSE OF THE STUDY:
Type-2 diabetes is one of the most widespread diseases in the industrialized
countries and its incidence is found to be more among the prosperous people compared to
primitive or economically deprive people. The disease affects the population in the prime
of life. People are at greater risk of type-2 diabetes due to improper dietary practices,
unhealthy life style, socio-economic situation, smoking, mental stress and lack of
physical exercise. Too much fat, especially saturated fat from meat or dairy products, too
much sugar and salt, too many calories and not enough whole grains, fruits and vegetable
are the primary dietary problems challenging the population.
Indians are genetically more predisposed to having type-2, diabetes the major
factor responsible for the rise in ailment is rapid urbanization which has brought
significant life style & dietary habit changes in the population. Smoking, cholesterol,
high blood pressure and lack of exercise are the main risk factors associated with type-2
diabetes. The onset of type-2 diabetes can be prevented by reducing refined carbohydrate
and cholesterol consumption, eating fewer foods high in total fat, replacing part of
saturated fat with unsaturated fat, taking foods high in complex carbohydrate as
substitutes for foods higher in refined carbohydrates. Diets rich in fruits and vegetables
and grains products that contain some type of dietary fiber, particularly soluble fiber, may
reduce the risk of type-2 diabetes. Risk of type-2 diabetes can also be reduced by quitting
smoking, regular physical exercise, controlling blood pressure and weight.
Indian diet is mainly cereal based. Cereals are not only a good source of complex
carbohydrates but also provide substantial amount of vitamins, minerals, phytochemicals
and antioxidants. Grains are eaten as whole, broken or in the form of flour in number of
preparations and in different meals of a day. Roti is the main preparation and Missi Roti,
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a type of roti is eaten in North India. Missi roti is considered good for diabetic as it helps
to maintain blood glucose level (Sharma and Choudhary, 2006).
In preview of the subject the purpose of the present study was to determine glycemic
index of selected and formulated food products and assessment of their therapeutic
potential in type-2 diabetes’’ and the study mainly focuses on modification of chapattis
since it is main course and a major carbohydrate contributor in the North Indian meal.
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