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Nutrition Recommendations andInterventions for Diabetes

A position statement of the American Diabetes Association

AMERICAN DIABETES ASSOCIATION

Medical nutrition therapy (MNT) isimportant in preventing diabetes,managing existing diabetes, and

preventing, or at least slowing, the rate ofdevelopment of diabetes complications. Itis, therefore, important at all levels of di-abetes prevention (see Table 1). MNT isalso an integral component of diabetesself-management education (or training).This position statement provides evi-

dence-based recommendations and inter-ventions for diabetes MNT. The previousposition statement with accompanyingtechnical review was published in 2002(1) and modified slightly in 2004 (2). Thisstatement updates previous positionstatements, focuses on key referencespublished since the year 2000, and usesgrading according to the level of evidenceavailable based on the American Diabetes

Association evidence-grading system.Since overweight and obesity are closelylinked to diabetes, particular attention ispaid to this area of MNT.

The goal of these recommendations isto make people with diabetes and healthcare providers aware of beneficial nutri-tion interventions. This requires the useof the best available scientific evidencewhile taking into account treatment goals,strategies to attain such goals, andchanges individuals with diabetes arewilling and able to make. Achieving nu-trition-related goals requires a coordi-nated team effort that includes the personwith diabetes and involves him or her inthe decision-making process. It is recom-

mended that a registered dietitian, knowl-edgeable and skilled in MNT, be the teammember who plays the leading role inproviding nutrition care. However, it is

important that all team members, includ-ing physicians and nurses, be knowledge-a b l e a b o u t M N T a n d s u p p o r t i t simplementation.

MNT, as illustrated in Table 1, plays arole in all three levels of diabetes-relatedprevention targeted by the U.S. Depart-ment of Health and Human Services. Pri-mary prevention interventions seek todelay or halt the development of diabetes.

This involves public health measures toreduce the prevalence of obesity and in-cludes MNT for individuals with pre-diabetes. Secondary and tertiary preventioninterventions include MNT for individualswith diabetes and seek to prevent (sec-ondary) or control (tertiary) complica-tions of diabetes.

GOALS OF MNT FORPREVENTION ANDTREATMENT OF DIABETES

Goals of MNT that apply toindividuals at risk for diabetes or

with pre-diabetesTo decrease the risk of diabetes and car-diovascular disease (CVD) by promotinghealthy food choices and physical activityleading to moderate weight loss that ismaintained.

Goals of MNT that apply toindividuals with diabetes1) Achieve and maintain

Blood glucose levels in the normalrange or as close to normal as is safely

possible A lipid and lipoprotein profile that re-

duces the risk for vascular disease Blood pressure levels in the normal

range or as close to normal as is safelypossible

2) To prevent, or at least slow, the rate ofdevelopment of the chronic complica-tions of diabetes by modifying nutrientintake and lifestyle3) To address individual nutrition needs,taking into account personal and culturalpreferences and willingness to change4) To maintain the pleasure of eating byonly limiting food choices when indicatedby scientific evidence

Goals of MNT that apply to specificsituations1) For youth with type 1 diabetes, youthwith type 2 diabetes, pregnant and lactat-ing women, and older adults with diabe-tes, to meet the nutritional needs of theseunique times in the life cycle.

2) For individuals treated with insulin orinsulin secretagogues, to provide self-management training for safe conduct ofexercise, including the prevention andtreatment of hypoglycemia, and diabetestreatment during acute illness.

EFFECTIVENESS OF MNTRecommendations Individuals who have pre-diabetes or

diabetes should receive individualizedMNT; such therapy is best provided bya registered dietitian familiar with thecomponents of diabetes MNT. (B)

Nutrition counseling should be sensi-tive to the personal needs, willingnessto change, and ability to make changesof the individual with pre-diabetes ordiabetes. (E)

Clinical trials/outcome studies ofMNT have reported decreases in HbA1c

(A1C) of1% in type 1 diabetes and12% in type 2 diabetes, depending onthe duration of diabetes (3,4). Meta-analysis of studies in nondiabetic, free-living subjects and expert committeesreport that MNT reduces LDL cholesterolby 1525 mg/dl (5,6). After initiation ofMNT, improvements were apparent in36 months. Meta-analysis and expertcommittees also support a role for lifestylemodification in treating hypertension(7,8).

Originally approved 2006. Revised 2007.Writing panel: John P. Bantle (Co-Chair), Judith Wylie-Rosett (Co-Chair), Ann L. Albright, Caroline M.

Apovian, Nathaniel G. Clark, Marion J. Franz, Byron J. Hoogwerf, Alice H. Lichtenstein, Elizabeth Mayer-Davis, Arshag D. Mooradian, and Madelyn L. Wheeler.

Abbreviations: CHD, coronary heart disease; CKD, chronic kidney disease; CVD, cardiovascular disease;DPP, Diabetes Prevention Program; FDA, Food and Drug Administration; GDM, gestational diabetes mel-litus; MNT, medical nutrition therapy; RDA, recommended dietary allowance; USDA, U.S. Department of

Agriculture.DOI: 10.2337/dc08-S061 2008 by the American Diabetes Association.

P O S I T I O N S T A T E M E N T

DIABETES CARE, VOLUME 31, SUPPLEMENT 1, JANUARY 2008 S61


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ENERGY BALANCE,OVERWEIGHT, ANDOBESITY

Recommendations In overweight and obese insulin-

resistant individuals, modest weightloss has been shown to improve insulinresistance. Thus, weight loss is recom-mended for all such individuals whohave or are at risk for diabetes. (A)

For weight loss, either low-carbohy-drate or low-fat calorie-restricted dietsmay be effective in the short term (up to

1 year). (A) For patients on low-carbohydrate diets,

monitor lipid profiles, renal function,and protein intake (in those with ne-phropathy), and adjust hypoglycemictherapy as needed. (E)

Physical activity and behavior modifi-cation are important components ofweight loss programs and are mosthelpful in maintenance of weight loss.(B)

Weight loss medications may be con-sidered in the treatment of overweight

and obese individuals with type 2 dia-betes and can help achieve a 510%weight loss when combined with life-style modification. (B)

Bariatric surgery may be considered forsome individuals with type 2 diabetesand BMI 35 kg/m2 and can result inmarked improvements in glycemia.The long-term benefits and risks ofbariatric surgery in individuals with

pre-diabetes or diabetes continue to bestudied. (B)

The importance of controlling bodyweight in reducing risks related to diabe-tes is of great importance. Therefore,these nutrition recommendations start byconsidering energy balance and weightloss strategies. The National Heart, Lung,and Blood Institute guidelines defineoverweight as BMI 25 kg/m2 and obe-sity as BMI 30 kg/m2 (9). The risk ofcomorbidity associated with excess adi-pose tissue increases with BMIs in this

range and above. However, cliniciansshould be aware that in some Asian pop-ulations, the proportion of people at highrisk of type 2 diabetes and CVD is signif-icant at BMIs of23 kg/m2 (10). Visceralbody fat, as measured by waist circumfer-ence 35 inches in women and 40inches in men, is used in conjunctionwith BMI to assess risk of type 2 diabetesand CVD (Table 2) (9). Lower waist cir-cumference cut points (31 inches inwomen,35 inches in men) may be ap-propriate for Asian populations (11).

Because of the effects of obesity oninsulin resistance, weight loss is an im-portant therapeutic objective for individ-uals with pre-diabetes or diabetes (12).However, long-term weight loss is diffi-cult for most peopleto accomplish. This isprobably because the central nervous sys-tem plays an important role in regulatingenergy intake and expenditure. Short-term studies have demonstrated that

moderate weight loss (5% of body weight)in subjects with type 2 diabetes is associ-ated with decreased insulin resistance,improved measures of glycemia and li-pemia, and reduced blood pressure (13).Longer-term studies (52 weeks) usingpharmacotherapy for weight loss in adultswith type 2 diabetes produced modest re-ductions in weight and A1C (14), al-though improvement in A1Cwas notseenin all studies (15,16). Look AHEAD (Ac-tion for Health in Diabetes) is a large Na-tional Institutes of Healthsponsoredclinical trial designed to determine iflong-term weight loss will improve glyce-mia and prevent cardiovascular events(17). When completed, this study shouldprovide insight into the effects of long-term weight loss on important clinicaloutcomes.

Evidence demonstrates that struc-tured, intensive lifestyle programs involv-ing participant education, individualizedcounseling, reduced dietary energy andfat (30% of total energy) intake, regularphysical activity, and frequent participantcontact are necessary to produce long-

term weight loss of 57% of startingweight (1). The role of lifestyle modifica-tion in the management of weight andtype 2 diabetes was recently reviewed(13). Although structured lifestyle pro-grams have been effective when deliveredin well-funded clinical trials, it is not clearhow the results should be translated intoclinical practice. Organization, delivery,and funding of lifestyle interventions areall issues that must be addressed. Third-party payers may not provide adequatebenefits for sufficient MNT frequency and

time to achieve weight loss goals (18).Exercise and physical activity, bythemselves, have only a modest weightloss effect. However, exercise and physi-cal activity are to be encouraged becausethey improve insulin sensitivity indepen-dent of weight loss, acutely lower bloodglucose, and are important in long-termmaintenance of weight loss (1). Weightloss with behavioral therapy alone alsohas been modest, and behavioral ap-proaches may be most useful as an ad-

junct to other weight loss strategies.Standard weight loss diets provide

Table 1Nutrition and MNT

Primary prevention to prevent diabetes: Secondary prevention to prevent complications: Tertiary prevention to prevent morbidity and mortality:

Use MNT and public health

interventions in those with obesityand pre-diabetes

Use MNT for metabolic control of diabetes Use MNT to delay and manage complications of

diabetes

Table 2Classification of overweight and obesity by BMI, waist circumference, and associ-ated disease risk

BMI (kg/m2)

Obesity

class

Disease risk*

WC: men40 inches;

women35 inches

WC: men40inches; women

35 inches

Underweight 18.5

Normal 18.524.9Overweight 25.029.9 Increased High

Obesity 30.034.9 I High Very high35.039.9 II Very high Very high

Extreme obesity 40 III Extremely high Extremely high

*Disease risk for type 2 diabetes, hypertension, and CVD. Adapted from ref. 9. WC, waist circumference.

Nutrition recommendations and interventions

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5001,000 fewer calories than estimatedto be necessary for weight maintenanceand initially result in a loss of12 lb/week. Although many people can losesome weight (as much as 10% of initialweight in 6 months) with such diets,without continued support and follow-up, people usually regain the weight they

have lost.The optimal macronutrient distri-

bution of weight loss diets has not beenestablished. Although low-fat diets havetraditionally been promoted for weightloss, two randomized controlled trialsfound that subjects on low-carbohy-drate diets lost more weight at 6 monthsthan subjects on low-fat diets (19,20).

Another study of overweight womenrandomized to one of four diets showedsignificantly more weight loss at 12months with the Atkins low-carbohy-

drate diet than with higher-carbohy-drate diets (20a). However, at 1 year,the difference in weight loss betweenthe low-carbohydrate and low-fat dietswas not significant and weight loss wasmodest with both diets. Changes in se-rum triglyceride and HDL cholesterolwere more favorable with the low-carbohydrate diets. In one study, thosesubjects with type 2 diabetes demon-strated a greater decrease in A1C with alow-carbohydrate diet than with a low-fat diet (20). A recent meta-analysiss h o w e d t h a t a t 6 m o n t h s , l o w -

carbohydrate diets were associated withgreater improvements in triglycerideand HDL cholesterol concentrationsthan low-fat diets; however, LDL cho-lesterol was significantly higher on thelow-carbohydrate diets (21). Furtherresearch is needed to determine thelong-term efficacy and safety of low-carbohydrate diets (13). The recom-mended dietary allowance (RDA) fordigestible carbohydrate is 130 g/dayand is based on providing adequate glu-cose as the required fuel for the central

nervous system without reliance on glu-cose production from ingested proteinor fat (22). Although brain fuel needscan be met on lower-carbohydrate di-ets, long-term metabolic effects of very-low-carbohydrate diets are unclear, andsuch diets eliminate many foods that areimportant sources of energy, fiber, vita-mins, and minerals and are important indietary palatability (22).

Meal replacements (liquid or solidprepackaged) provide a defined amountof energy, often as a formula product. Useof meal replacements once or twice daily

to replace a usual meal can result in sig-nificant weight loss. Meal replacementsare an important part of the Look AHEADweight loss intervention (17). However,meal replacement therapy must be con-tinued indefinitely if weight loss is to bemaintained.

Very-low-calorie diets provide800

calories daily and produce substantialweight loss and rapid improvements inglycemia and lipemia in individuals withtype 2 diabetes. When very-low-caloriediets are stopped and self-selected mealsare reintroduced, weight regain is com-mon. Thus, very-low-calorie diets appearto have limited utility in the treatment oftype 2 diabetes and should only be con-sidered in conjunction with a structuredweight loss program.

The available data suggest that weightloss medications may be useful in the

treatment of overweight individuals withand at risk for type 2 diabetes and canhelp achieve a 510% weight loss whencombined with lifestyle change (14). Ac-cording to their labels, these medicationsshould only be used in people with dia-betes who have BMI 27.0 kg/m2.

Gastric reduction surgery can be aneffective weight loss treatment for obesityand may be considered in people with di-abetes who have BMI35 kg/m2. A meta-analysis of studies of bariatric surgeryreported that 77% of individuals withtype 2 diabetes had complete resolution

of diabetes (normalization of blood glu-cose levels in the absence of medications),and diabetes was resolved or improved in86% (23). In the Swedish Obese Subjectsstudy, a 10-year follow-up of individualsundergoing bariatric surgery, 36%of sub-

jects with diabetes had resolution of dia-betes compared with 13% of matchedcontrol subjects (24). All cardiovascularrisk factors except hypercholesterolemiaimproved in the surgical patients.

NUTRITION

RECOMMENDATIONS ANDINTERVENTIONS FOR THEPREVENTION OF DIABETES(PRIMARY PREVENTION)

Recommendations Among individuals at high risk for de-

veloping type 2 diabetes, structuredprograms that emphasize lifestylechanges that include moderate weightloss (7% body weight) and regularphysical activity (150 min/week), withdietary strategies including reducedcalories and reduced intake of dietary

fat, can reduce the risk for developingdiabetes and are therefore recom-mended. (A)

Individuals at high risk for type 2 dia-betes should be encouraged to achievethe U.S. Department of Agriculture(USDA) recommendation for dietary fi-ber (14 g fiber/1,000 kcal) and foods

containing whole grains (one-half ofgrain intake). (B)

There is not sufficient, consistent infor-mation to conclude that lowglycemicload diets reduce the risk for diabetes.Nevertheless, lowglycemic indexfoods that are rich in fiber and otherimportant nutrients are to be encour-aged. (E)

Observational studies report that mod-erate alcohol intakemay reduce the riskfor diabetes, but the data do not sup-port recommending alcohol consump-

tion to individuals at risk of diabetes.(B) No nutrition recommendation can be

made for preventing type 1 diabetes.(E)

Although there are insufficient data atpresent to warrant any specific recom-mendations for prevention of type 2 di-abetes in youth, it is reasonable to applyapproaches demonstrated to be effec-tive in adults, as long as nutritionalneeds for normal growth and develop-ment are maintained. (E)

The importance of preventing type2 diabetes is highlighted by the substan-tial worldwide increase in the preva-le nc e of dia b e t e s in re c e nt ye a rs.Genetic susceptibility appears to play apowerful role in the occurrence of type2 diabetes. However, given that popu-lation gene pools shift very slowly overtime, the current epidemic of diabeteslikely reflects changes in lifestyle lead-ing to diabetes. Lifestyle changes char-acterized by increased energy intakeand decreased physical activity appearto have together promoted overweightand obesity, which are strong risk fac-tors for diabetes.

Several studies have demonstratedthe potential for moderate, sustainedweight loss to substantially reduce therisk for type 2 diabetes, regardless ofwhether weight loss was achieved by life-style changes alone or with adjunctivetherapies such as medication or bariatric-surgery (see ENERGY BALANCE section) (1).Moreover, both moderate-intensity andvigorous exercise can improve insulin

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sensitivity, independent of weight loss,and reduce risk for type 2 diabetes (1).

Clinical trial data from both theFinnish Diabetes Prevention study (25)and the Diabetes Prevention Program(DPP) in the U.S (26) strongly supportthe potential for moderate weight loss toreduce the risk for type 2 diabetes. The

lifestyle intervention in both trials em-phasized lifestyle changes that includedmoderate weight loss (7% of bodyweight) and regular physical activity(150 min/week), with dietary strategiesto reduce intake of fat and calories. Inthe DPP, subjects in the lifestyle inter-vention group reported dietary fat in-takes of34% of energy at baseline and28% of energy after 1 year of interven-tion (27). A majority of subjects in thelifestyle intervention group met thephysical activity goal of 150 min/week

of moderate physical activity (26,28). Inaddition to preventing diabetes, theDPP lifestyle intervention improvedseveral CVD risk factors, includingdsylipidemia, hypertension, and in-flammatory markers (29,30). The DPPanalysis indicated that lifestyle inter-vention was cost-effective (31), butother analyses suggest that the expectedcosts needed to be reduced (32).

Both the Finnish Diabetes Preven-tion study and the DPP focused on re-duced intake of calories (using reduceddietary fat as a dietary intervention). Of

note, reduced intake of fat, particularlysaturated fat, may reduce risk for diabe-tes by producing an energy-indepen-dent improvement in insulin resistance(1,33,34), as well as by promotingweight loss. It is possible that reductionin other macronutrients (e.g., carbohy-drates) would also be effective in pre-vention of diabetes through promotionof weight loss; however, clinical trialdata on the efficacy of low-carbohydratediets for primary prevention of type 2diabetes are not available.

Several studies have provided evi-dence for reduced risk of diabetes withincreased intake of whole grains and di-etary fiber (1,3537). Whole graincontaining foods have been associatedwith improved insulin sensitivity, inde-pendent of body weight, and dietary fiberhas been associated with improved insu-lin sensitivity and improved ability to se-crete insulin adequately to overcomeinsulin resistance (38). There is debate asto the potential role of lowglycemic in-dex and glycemic load diets in preven-tion of type 2 diabetes. Although some

studies have demonstrated an associationbetween glycemic load and risk for diabe-tes, other studies have been unable toconfirm this relationship, and a recent re-port showed no association of glycemicindex/glycemic load with insulin sensitiv-ity (39).

Thus, there is not sufficient, consis-

tent information to conclude that lowglycemic load diets reduce risk fordiabetes. Prospective randomized clinicaltrials will be necessary to resolve this is-sue. Nevertheless, lowglycemic indexfoods that are rich in fiber and other im-portant nutrients are to be encouraged. A2004 American Diabetes Associationstatement reviewed this issue in depth(40), and issues related to the role of gly-cemic index and glycemic load in dia-betes management are addressed in moredetail in the CARBOHYDRATE section of this

document.Observational studies suggest a U- or

J-shaped association between moderateconsumption of alcohol (one to threedrinks [1545 g alcohol] per day) anddecreased risk of type 2 diabetes (41,42),coronary heart disease (CHD) (42,43),and stroke (44). However, heavy con-sumption of alcohol (greater than threedrinks per day), may be associated withincreased incidence of diabetes (42). If al-cohol is consumed, recommendationsfrom the 2005 USDA Dietary Guidelines

for Americans suggest no more than onedrink per day for women and two drinksper day for men (45).

Although selected micronutrientsmay affect glucose and insulin metabo-lism, to date, there are no convincing datathat document their role in the develop-ment of diabetes.

Diabetes in youthNo nutrition recommendations can bemade for the prevention of type 1 diabetesat this time (1). Increasing overweight

and obesity in youth appears to be relatedto the increased prevalence of type 2 dia-betes, particularly in minority adoles-cents. Although there are insufficient dataat present to warrant any specific recom-mendations for the prevention of type 2diabetes in youth, interventions similar tothose shown to be effective for preventionof type 2 diabetes in adults (lifestylechanges including reduced energy intakeand regular physical activity) are likely tobe beneficial. Clinical trials of such inter-ventions are ongoing in children.

NUTRITIONRECOMMENDATIONS FORTHE MANAGEMENT OFDIABETES (SECONDARYPREVENTION)

Carbohydrate in diabetesmanagement

Recommendations A dietary pattern that includes carbo-

hydrate from fruits, vegetables, wholegrains, legumes, and low-fat milk is en-couraged for good health. (B)

Monitoring carbohydrate, whether bycarbohydrate counting, exchanges, orexperienced-based estimation remainsa key strategy in achieving glycemiccontrol. (A)

The use of glycemic index and load mayprovide a modest additional benefit

over that observed when total carbohy-drate is considered alone. (B) Sucrose-containing foods can be sub-

stituted for other carbohydrates in themeal plan or, if added to the meal plan,covered with insulin or other glucose-lowering medications. Care should betaken to avoid excess energy intake. (A)

As for the general population, peoplewith diabetes are encouraged to con-sume a variety of fiber-containingfoods. However, evidence is lacking torecommend a higher fiber intake forpeople with diabetes than for the pop-

ulation as a whole. (B) Sugar alcohols and nonnutritive sweet-

eners are safe when consumed withinthedaily intake levels established by theFood and Drug Administration (FDA).(A)

Control of blood glucose in an effortto achieve normal or near-normal levels isa primary goal of diabetes management.Food and nutrition interventions that re-duce postprandial blood glucose excur-sions are important in this regard, since

dietary carbohydrate is the major deter-minant of postprandial glucose levels.Low-carbohydrate diets might seem to bea logical approach to lowering postpran-dial glucose. However, foods that containcarbohydrate are important sources of en-ergy, fiber, vitamins, and minerals and areimportant in dietary palatability. There-fore, these foods are important compo-nents of the diet for individuals withdiabetes. Issues related to carbohydrateand glycemia have previously been exten-sively reviewed in American Diabetes

Association reports and nutrition recom-




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mendations for the general public (1,2,22,40,45).

Blood glucose concentration follow-ing a meal is primarily determined by therate of appearance of glucose in the bloodstream (digestion and absorption) and itsclearance from the circulation (40). Insu-lin secretory response normally maintains

blood glucose in a narrow range, but inindividuals with diabetes, defects in insu-lin action, insulin secretion, or both im-pair regulation of postprandial glucose inresponse to dietary carbohydrate. Boththe quantity and the type or source of car-bohydrates found in foods influence post-prandial glucose levels.Amount and type of carbohydrate. A2004 ADA statement addressed the ef-fects of the amount and type of carbohy-drate in diabetes management (40). Asnoted previously, the RDA for carbohy-

drate (130 g/day) is an average minimumrequirement (22). There are no trials spe-cifically in patients with diabetes restrict-ing total carbohydrate to 130 g/day.However, 1-year follow-up data from asmall weight-loss trial (20) indicate,among the subset with diabetes, that thereduction in fasting glucose was 21 mg/dl(1.17 mmol/l) and 28 mg/dl (1.55mmol/l) for the low-carbohydrate andlow-fat diets, respectively, with no signif-icant difference for change in A1C levels.The 1-year follow-up data also indicatethat the macronutrient composition of the

treatment groups only differed with re-spect to carbohydrate intake (meanintakeof 230 vs. 120 g). Thus, questions aboutthe long-term effects on intake and me-tabolism, as well as safety, need furtherresearch.

The amount of carbohydrate ingestedis usually the primary determinant ofpostprandial response, but the type of car-bohydrate also affects this response. In-trinsic variables that influence theeffect ofcarbohydrate-containing foods on bloodglucose response include the specific type

of food ingested, type of starch (amyloseversus amylopectin), style of preparation(cooking method and time, amount ofheat or moisture used), ripeness, and de-gree of processing. Extrinsic variables thatmay influence glucose response includefasting or preprandial blood glucose level,macronutrient distribution of the meal inwhich the food is consumed, available in-sulin, and degree of insulin resistance.

The glycemic index of foods was de-veloped to compare the postprandial re-sponses to constant amounts of differentcarbohydrate-containing foods (46). The

glycemic index of a food is the increaseabove fasting in the blood glucose areaover 2 h after ingestion of a constantamount of that food (usually a 50-g car-bohydrate portion) divided by the re-sponse to a reference food (usuallyglucose or white bread). The glycemicloads of foods, meals, and diets are calcu-

lated by multiplying the glycemic index ofthe constituent foods by the amounts ofcarbohydrate in each food and then total-ing the values for all foods. Foods withlow glycemic indexes include oats,barley,bulgur, beans, lentils, legumes, pasta,pumpernickel (coarse rye) bread, apples,oranges, milk, yogurt, and ice cream. Fi-ber, fructose, lactose, and fat are dietaryconstituents that tend to lower glycemicresponse. Potential methodological prob-lems with the glycemic index have beennoted (47).

Several randomized clinical trialshave reported that lowglycemic indexdiets reduce glycemia in diabetic subjects,but other clinical trials have not con-firmed this effect (40). Moreover, thevariability in responses to specific carbo-hydrate-containing food is a concern(48). Nevertheless, a recent meta-analysisof lowglycemic index diet trials in dia-betic subjects showed that such diets pro-duced a 0.4% decrement in A1C whencompared with highglycemic index di-ets (49). However, it appears that mostindividuals already consume a moderate

glycemic index diet (39,50). Thus, it ap-pears that in individuals consuming ahighglycemic index diet, low glycemicindex diets can produce a modest benefit incontrolling postprandial hyperglycemia.

In diabetes management, it is impor-tant to match doses of insulin and insulinsecretagogues to the carbohydrate con-tent of meals. A variety of methods can beused to estimate the nutrient content ofmeals, including carbohydrate counting,the exchange system, and experience-based estimation. By testing pre- and

postprandial glucose, many individualsuse experience to evaluate and achievepostprandial glucose goals with a varietyof foods. To date, research has not dem-onstrated that one method of assessingthe relationship between carbohydrate in-take and blood glucose response is betterthan other methods.Fiber. As for the general population,people with diabetes are encouraged tochoose a variety of fiber-containing foodssuch as legumes, fiber-rich cereals (5 gfiber/serving), fruits, vegetables, andwhole grain products because they pro-

vide vitamins, minerals, and other sub-stances important for good health.Moreover, there are data suggesting thatconsuming a high-fiber diet (50 g fiber/day) reduces glycemia in subjects withtype 1 diabetes and glycemia, hyperinsu-linemia, and lipemia in subjects with type2 diabetes (1). Palatability, limited food

choices, and gastrointestinal side effectsare potential barriers to achieving suchhigh-fiber intakes. However, increased fi-ber intake appears to be desirable for peo-ple with diabetes, and a first prioritymight be to encouragethem to achieve thefiber intake goals set for the general pop-ulation of 14 g/1,000 kcal (22).Sweeteners. Substantial evidence fromclinical studies demonstrates that dietarysucrose does not increase glycemia morethan isocaloric amounts of starch (1).Thus, intake of sucrose and sucrose-

containing foods by people with diabetesdoes not need to be restricted because ofconcern about aggravating hyperglyce-mia. Sucrose can be substituted for othercarbohydrate sources in the meal plan or,if added to the meal plan, adequately cov-ered with insulin or another glucose-lowering medication. Additionally, intakeof other nutrients ingested with sucrose,such as fat, need to be taken into account,and care should be taken to avoid excessenergy intake.

In individuals with diabetes, fructoseproduces a lower postprandial glucose re-

sponse when it replaces sucrose or starchin the diet; however, this benefit is tem-pered by concern that fructose may ad-versely affect plasma lipids (1). Therefore,the use of added fructose as a sweeteningagent in the diabetic diet is not recom-mended. There is, however, no reason torecommend that people with diabetesavoid naturally occurring fructose infruits, vegetables, and other foods. Fruc-tose from these sources usually accountsfor only 3 4% of energy intake.

Reduced calorie sweeteners approved

by the FDA include sugar alcohols (poly-ols) such as erythritol, isomalt, lactitol,maltitol, mannitol, sorbitol, xylitol, taga-tose, and hydrogenated starch hydroly-sates. Studies of subjects with andwithout diabetes have shown that sugaralcohols produce a lower postprandialglucose response than sucrose or glucoseand have lower availableenergy (1). Sugaralcohols contain, on average, about 2 cal-ories/g (one-half the calories of othersweeteners such as sucrose). When calcu-lating carbohydrate content of foods con-taining sugar alcohols, subtraction of half

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the sugar alcohol grams from total carbo-hydrate grams is appropriate. Use of sugaralcohols as sweeteners reduces the risk ofdental caries. However, there is no evi-dence that the amounts of sugar alcoholslikely to be consumed will reduce glyce-mia, energy intake, or weight. The use ofsugar alcohols appears to be safe; how-

ever, they may cause diarrhea, especiallyin children.

The FDA has approved five nonnutri-tive sweeteners for use in the U.S. Theseare acesulfame potassium, aspartame,neotame, saccharin, and sucralose. Beforebeing allowed on the market, all under-went rigorous scrutiny and were shown tobe safe when consumed by the public, in-cluding people with diabetes and womenduring pregnancy. Clinical studies in-volving subjects without diabetes provideno indication that nonnutritive sweeten-

ers in foods will cause weight loss orweight gain (51).Resistant-starch/high-amylose foods.It has been proposed that foods contain-ing resistant starch (starch physically en-closed within intact cell structures as insome legumes, starch granules as in rawpotato, and retrograde amylose fromplants modified by plant breeding to in-crease amylose content) or high-amylosefoods, such as specially formulated corn-starch, may modify postprandial glycemicresponse, prevent hypoglycemia, and re-duce hyperglycemia. However, there are

no published long-term studies in sub-jects with diabetes to prove benefit fromthe use of resistant starch.

Dietary fat and cholesterol indiabetes management

Recommendations Limit saturated fat to7% of total cal-

ories. (A) Intake oftrans fat should be minimized.

(E) In individuals with diabetes, limit di-

etary cholesterol to

200 mg/day. (E) Two or more servings of fish per week(with the exception of commerciallyfried fish filets) provide n-3 polyunsat-urated fatty acids and are recom-mended. (B)

The primary goal with respect to di-etary fat in individuals with diabetes is tolimit saturated fatty acids, trans fatty ac-ids, and cholesterol intakes so as to re-duce risk for CVD. Saturated and transfatty acids are the principal dietary deter-minants of plasma LDL cholesterol. In

nondiabetic individuals, reducing satu-rated and trans fatty acids and cholesterolintakes decreases plasma total and LDLcholesterol. Reducing saturated fatty ac-ids may also reduce HDL cholesterol. Im-portantly, the ratio of LDL cholesterol toHDL cholesterol is not adversely affected.Studies in individuals with diabetes dem-

onstrating the effects of specific percent-ages of dietary saturated and trans fattyacids and specific amounts of dietary cho-lesterol on plasma lipids are not available.Therefore, because of a lack of specificinformation, it is recommended that thedietary goals for individuals with diabetesbe the same as for individuals with preex-isting CVD, since the two groups appearto have equivalent cardiovascular risk.Thus, saturated fatty acids 7% of totalenergy, minimal intake of trans fatty ac-ids, and cholesterol intake200 mg daily

are recommended.In metabolic studies in which energyintake and weight are held constant, dietslow in saturated fatty acids and high ineither carbohydrate or cis-monounsat-urated fatty acids lowered plasma LDLcholesterol equivalently (1,52). The high-carbohydrate diets (55% of total energyfrom carbohydrate) increased postpran-dial plasma glucose, insulin, and triglyc-erides when compared with highmonounsaturated fat diets. However,highmonounsaturated fat diets have notbeen shown to improve fasting plasma

glucose or A1C values. In other studies,when energy intake was reduced, the ad-verse effects of high-carbohydrate dietswere not observed (53,54). Individualv a r i a b i l i t y i n r e s p o n s e t o h i g h -carbohydrate diets suggests that theplasma triglyceride response to dietarymodification should be monitored care-fully, particularly in the absence of weightloss.

Diets high in polyunsaturated fattyacids appear to have effects similar tomonounsaturated fatty acids on plasma

lipid concentrations (5558). A modifiedMediterranean diet, in which polyunsat-urated fatty acids were substituted formonounsaturated fatty acids, reducedoverall mortality in elderly Europeans by7% (59). Very-long-chain n-3 polyunsat-urated fatty acid supplements have beenshown to lower plasma triglyceride levelsin individuals with type 2 diabetes whoare hypertriglyceridemic. Although theaccompanying small rise in plasma LDLcholesterol is of concern, an increase inHDL cholesterol may offset this concern(60). Glucose metabolism is not likely to

be adversely affected. Very-long-chainn-3 polyunsaturated fatty acid studies inindividuals with diabetes have primarilyused fish oil supplements. Consumptionof-3 fatty acids from fish or from sup-plements has been shown to reduce ad-verse CVD outcomes, but the evidence for-linolenic acid is sparse and inconclu-

sive (61). In addition to providing n-3fatty acids, fish frequently displace highsaturated fatcontaining foods from thediet (62). Two or more servings of fishper week (with the exception of com-mercially fried fish filets) (63,64) can berecommended.

Plant sterol and stanol esters blockthe intestinal absorption of dietary andbiliary cholesterol. In the general publicand in individuals with type 2 diabetes(65), intake of2 g/day plant sterols andstanols has been shown to lower plasma

total and LDL cholesterol. A wide range offoods and beverages are now availablethat contain plant sterols. If these prod-ucts are used, they should displace, ratherthan be added to, the diet to avoid weightgain. Soft gel capsules containing plantsterols are also available.

Protein in diabetes management

Recommendations For individuals with diabetes and nor-

mal renal function, there is insufficientevidence to suggest that usual protein

intake (1520% of energy) should bemodified. (E)

In individuals with type 2 diabetes, in-gested protein can increase insulin re-sponse without increasing plasmaglucose concentrations. Therefore, pro-tein should not be used to treat acute orprevent nighttime hypoglycemia. (A)

High-protein diets are not recom-mended as a method for weight loss atthis time. The long-term effects of pro-tein intake 20% of calories on diabe-tes management and its complications

are unknown. Although such diets mayproduce short-term weight loss andimproved glycemia, it has not been es-tablished that these benefits are main-tained long term, and long-term effectson kidney function for persons with di-abetes are unknown. (E)

The Dietary Reference Intakes ac-ceptable macronutrient distributionrange for protein is 1035% of energy in-take, with 15% being the average adultintake in the U.S. and Canada (22). TheRDA is 0.8 g good-quality protein kg




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body wt1 day1 (on average, 10% ofcalories) (22). Good-quality proteinsources are defined as having high PD-CAAS (protein digestibilitycorrectedamino acid scoring pattern) scores andprovide all nine indispensable amino ac-ids. Examples are meat, poultry, fish,eggs, milk, cheese, and soy. Sources not in

the good category include cereals,grains, nuts, and vegetables. In meal plan-ning, protein intake should be greaterthan 0.8 g kg1 day1 to account formixed protein quality in foods.

The dietary intake of protein for indi-viduals with diabetes is similar to that ofthe general public and usually does notexceed 20% of energy intake. A numberof studies in healthy individuals and inindividuals with type 2 diabetes havedemonstrated that glucose producedfrom ingested protein does not increase

plasma glucose concentration but doesproduce increases in serum insulin re-sponses (1,66). Abnormalities in proteinmetabolism may be caused by insulin de-ficiency and insulin resistance; however,these are usually corrected with goodblood glucose control (67).

Small, short-term studies in diabetessuggest that diets with protein content20% of total energy reduce glucose andinsulin concentrations, reduce appetite,and increase satiety (68,69). However,the effects of high-protein diets on long-

term regulation of energy intake, satiety,weight, and the ability of individuals tofollow such diets long term have not beenadequately studied.

Dietary protein and its relationshipsto hypoglycemia and nephropathy are ad-dressed in later sections.

Optimal mix of macronutrientsAlthough numerous studies have at-tempted to identify the optimal mix ofmacronutrients for the diabetic diet, it isunlikely that one such combination ofmacronutrients exists. The best mix ofcarbohydrate, protein, and fat appears tovary depending on individual circum-stances. For those individuals seekingguidance as to macronutrient distributionin healthy adults, the Dietary ReferenceIntakes (DRIs) may be helpful (22). Itmust be clearly recognized that regardlessof the macronutrient mix, total caloric in-take must be appropriate to weight man-agement goals. Further, individualizationof the macronutrient composition will de-pend on the metabolic status of the pa-tient (e.g., lipid profile).

Alcohol in diabetes management

Recommendations If adults with diabetes choose to use

alcohol, daily intake should be limitedto a moderate amount (one drink perday or less for women and two drinks

per day or less for men). (E) To reduce risk of nocturnal hypoglyce-

mia in individuals using insulin or in-sulin secretagogues, alcohol should beconsumed with food. (E)

In individuals with diabetes, moderatealcohol consumption (when ingestedalone) has no acute effect on glucoseand insulin concentrations but carbo-hydrate coingested with alcohol (as in amixed drink) may raise blood glucose.(B)

Abstention from alcohol should beadvised for people with a history of alco-hol abuse or dependence, women duringpregnancy, and people with medicalproblems such as liver disease, pancreati-tis, advanced neuropathy, or severe hy-pertriglyceridemia. If individuals chooseto use alcohol, intake should be limited toa moderate amount (less than one drinkper day for adult women and less thantwo drinks per day for adult men). Onealcohol containing beverage is defined as12 oz beer, 5 oz wine, or 1.5 oz distilledspirits. Each contains 15 g alcohol.

Moderate amounts of alcohol, wheningested with food, have minimal acuteeffects on plasma glucose and serum in-sulin concentrations (42). However, car-bohydrate coingested with alcohol mayraise blood glucose. For individuals usinginsulin or insulin secretagogues, alcoholshould be consumed with food to avoidhypoglycemia. Evening consumption ofalcohol may increase the risk of nocturnaland fasting hypoglycemia, particularly inindividuals with type 1 diabetes (70). Oc-casional use of alcoholic beverages should

be considered an addition to the regularmeal plan, and no food should be omit-ted. Excessive amounts of alcohol (threeor more drinks per day), on a consistentbasis, contributes to hyperglycemia (42).

In individuals with diabetes, light tomoderate alcohol intake (one to twodrinks per day; 1530 g alcohol) is asso-ciated with a decreased risk of CVD (42).The reduction in CVD does not appear tobe due to an increase in plasma HDL cho-lesterol. The type of alcohol-containingbeverage consumed does not appear tomake a difference.

Micronutrients in diabetesmanagement

Recommendations There is no clear evidence of benefit

from vitamin or mineral supplementa-tion in people with diabetes (compared

with the general population) who donot have underlying deficiencies. (A)

Routine supplementation with antioxi-dants, such as vitamins E and C andcarotene, is not advised because of lackof evidence of efficacy and concern re-lated to long-term safety. (A)

Benefit from chromium supplementa-tion in individuals with diabetes or obe-sity has not been clearly demonstratedand therefore can not be recom-mended. (E)

Uncontrolled diabetes is often associ-ated with micronutrient deficiencies (71).Individuals with diabetes should be awareof the importance of acquiring daily vita-min and mineral requirements from nat-ural food sources and a balanced diet.Health care providers should focus on nu-trition counseling rather than micronutri-ent supplementation in order to reachmetabolic control of their patients. Re-search including long-term trials isneeded to assess the safety and potentiallybeneficial role of chromium, magnesium,

and antioxidant supplements and othercomplementary therapies in the manage-ment of type 2 diabetes (71a,71b). In se-lect groups such as the elderly, pregnantor lactating women, strict vegetarians, orthose on calorie-restricted diets, a multi-vitamin supplement may be needed (1).Antioxidants in diabetes management.Since diabetes may be a state of increasedoxidative stress, there has been interest inantioxidant therapy. Unfortunately, thereare no studies examining the effects of di-etary intervention on circulating levels ofantioxidants and inflammatory biomark-ers in diabetic volunteers. The few smallclinical studies involving diabetes andfunctional foods thought to have high an-tioxidant potential (e.g., tea, cocoa, cof-fee) are inconclusive. Clinical trial datanot only indicate the lack of benefit withrespect to glycemic control and progres-sion of complications but also provide ev-idence of the potential harm of vitamin E,carotene, and other antioxidant supple-ments (1,72,73). In addition, availabledata do not support the use of antioxidantsupplements for CVD risk reduction (74).

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Chromium, other minerals, and herbsin diabetes management. Chromium,potassium, magnesium, and possibly zincdeficiency may aggravate carbohydrateintolerance. Serum levels can readily de-tect the need for potassium or magnesiumreplacement, but detecting deficiency ofzinc or chromium is more difficult (75).

In the late 1990s, two randomized place-bo-controlled studies in China found thatchromium supplementation had benefi-cial effects on glycemia (7678), but thechromium status of the study populationswas not evaluated either at baseline or fol-lowing supplementation. Data from re-cent small studies indicate that chromiumsupplementation may have a role in themanagement of glucose intolerance, ges-tational diabetes mellitus (GDM), andcorticosteroid-induced diabetes (7678).However, other well-designed studies

have failed to demonstrate any significantbenefit of chromium supplementation inindividuals with impaired glucose intol-erance or type 2 diabetes (79,80). Simi-larly, a meta-analysis of randomizedcontrolled trials failed to demonstrate anybenefit of chromium picolinate supple-mentation in reducing body weight (81).The FDA concluded that although a smallstudy suggested that chromium picoli-nate may reduce insulin resistance, theexistence of such a relationship betweenchromium picolinate and either insulinresistance or type 2 diabetes was uncer-

tain (http:/www.cfsan.fda.gov/dms/qhccr.html).

There is insufficient evidence to dem-onstrate efficacy of individual herbs andsupplements in diabetes management(82). In addition, commercially availableproducts are not standardized and vary inthe content of active ingredients. Herbalpreparations also have the potential to in-teract with othermedications (83).There-fore, it is important that health careproviders be aware when patients with di-abetes are using these products and look

for unusual side effects and herb-drug orherb-herb interactions

NUTRITIONINTERVENTIONS FORSPECIFIC POPULATIONS

Nutrition interventions for type 1diabetes

Recommendations For individuals with type 1 diabetes,

insulin therapy should be integrated

into an individuals dietary and physi-cal activity pattern. (E)

Individuals using rapid-acting insulinby injection or an insulin pump shouldadjust the meal and snack insulin dosesbased on the carbohydrate content ofthe meals and snacks. (A)

For individuals using fixed daily insulin

doses, carbohydrate intake on a day-to-day basis should be kept consistentwith respect to time and amount. (C)

For planned exercise, insulin doses canbe adjusted. For unplanned exercise,extra carbohydrate may be needed. (E)

The first nutrition priority for indi-viduals requiring insulin therapy is to in-tegrate an insulin regimen into theirlifestyle. With the many insulin optionsnow available, an appropriate insulin regi-men can usually be developed to conform

to an individuals preferred meal routine,food choices, and physical activity pattern.For individuals receiving basal-bolus in-sulin therapy, the total carbohydrate con-tent of meals and snacks is the majordeterminant of bolus insulin doses (84).Insulin-to-carbohydrate ratios can beused to adjust mealtime insulin doses.Several methods can be used to estimatethe nutrient content of meals, includingcarbohydrate counting, the exchange sys-tem, and experience-based estimation.The DAFNE (Dose Adjustment for Nor-

mal Eating) study (85) demonstrated thatpatients can learn how to use glucose test-ing to better match insulin to carbohy-drate intake. Improvement in A1Cwithout a significant increase in severehypoglycemia was demonstrated, as werepositive effects on quality of life, satisfac-tion with treatment, and psychologicalwell-being, even though increases in thenumber of insulin injections and bloodglucose tests were necessary.

For planned exercise, reduction in in-sulin dosage is the preferred method toprevent hypoglycemia (86). For un-planned exercise, intake of additional car-bohydrate is usually needed. Moderate-intensity exercise increases glucoseutilization by 23 mg kg1 min1

above usual requirements (87). Thus, a70-kg person would need 1015 g ad-ditional carbohydrate per hour of moder-ate intensity physical activity. Morecarbohydrate is needed for intense activity.

A 2005 American Diabetes Associa-tion statement addresses diabetes MNTfor children and adolescents with type 1diabetes (88).

Nutrition interventions for type 2diabetes

Recommendations Individuals with type 2 diabetes are en-

couraged to implement lifestyle modi-fications that reduce intakes of energy,saturated and trans fatty acids, choles-

terol, and sodium and to increase phys-ical activity in an effort to improveglycemia, dyslipidemia, and bloodpressure. (E)

Plasma glucose monitoring can be usedto determine whether adjustments infoods and meals will be sufficient toachieve blood glucose goals or if medi-cation(s) needs to be combined withMNT. (E)

Healthy lifestyle nutrition recom-mendations for the general public are also

appropriate for individuals with type 2diabetes. Because many individuals withtype 2 diabetes are overweight andinsulinresistant, MNT should emphasize lifestylechanges that result in reduced energy in-take and increased energy expenditurethrough physical activity. Because manyindividuals also have dyslipidemia andhypertension, reducing saturated andtrans fatty acids, cholesterol, and sodiumis often desirable. Therefore, the first nu-trition priority is to encourage individualswith type 2 diabetes to implement life-style strategies that will improve glyce-

mia, dyslipidemia, and blood pressure.Although there are similarities to those

above for type 1 diabetes, MNTrecommen-dationsfor established type2 diabetes differin several aspects from both recommen-dations for type 1 diabetes and the pre-vention of diabetes. MNT progresses fromprevention of overweight and obesity, toimproving insulin resistance and prevent-ing or delaying the onset of diabetes, andto contributing to improved metaboliccontrol in those with diabetes. With es-tablished type 2 diabetes treated with

fixed doses of insulin or insulin secreta-gogues, consistency in timing and carbo-hydrate content of meals is important.However, rapid-acting insulins and rap-id-acting insulin secretagogues allow formore flexible food intake and lifestyle asin individuals with type 1 diabetes.

Increased physical activity by individ-uals with type 2 diabetes can lead to im-proved glycemia, decreased insulinresistance, and a reduction in cardiovas-cular risk factors, independent of changein body weight. At least 150 min/week ofmoderate-intensity aerobic physical ac-




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tivity, distributed over at least 3 days andwith no more than 2 consecutive dayswithout physical activity is recommended(89). Resistance training is also effectivein improving glycemia and, in theabsenceof proliferative retinopathy, people withtype 2 diabetes can be encouraged to per-form resistance exercise three times a

week (89).

Nutrition interventions forpregnancy and lactation withdiabetes

Recommendations Adequate energy intake that provides

appropriate weight gain is recom-mended during pregnancy. Weight lossis not recommended; however, foroverweight and obese women withGDM, modest energy and carbohydrate

restriction may be appropriate. (E) Ketonemia from ketoacidosis or starva-tion ketosis should be avoided. (C)

MNT for GDM focuses on food choicesfor appropriate weight gain, normogly-cemia, and absence of ketones. (E)

Because GDM is a risk factor for subse-quent type 2 diabetes, after delivery,lifestyle modifications aimed at reduc-ing weight and increasing physical ac-tivity are recommended. (A)

Prepregnancy MNT includes an indi-vidualized prenatal meal plan to optimize

blood glucose control. During pregnancy,the distribution of energy and carbohy-drate intake should be based on the wom-ans food and eating habits and plasmaglucose responses. Due to the continuousfetal draw of glucose from the mother,maintaining consistency of times andamounts of food eaten are important toavoidance of hypoglycemia. Plasma glu-cose monitoring and daily food recordsprovide valuable information for insulinand meal plan adjustments.

MNT for GDM primarily involves a

carbohydrate-controlled meal plan thatpromotes optimal nutrition for maternaland fetal health with adequate energy forappropriate gestational weight gain,achievement and maintenance of normo-glycemia, and absence of ketosis. Specificnutrition and food recommendations aredetermined and subsequently modifiedbased on individual assessment and self-monitoring of blood glucose. All womenwith GDM should receive MNT at thetime of diagnosis. A recent large clinicaltrial reported that treatment of GDM withnutrition therapy, bloodglucose monitor-

ing, and insulin therapy as required forglycemic control reduced serious perina-tal complications without increasing therate of cesarean delivery as comparedwith routine care (90). Maternal healthrelated quality of life was also improved.

Hypocaloric diets in obese womenwith GDM can result in ketonemia and

ketonuria. However, moderate caloric re-striction (reduction by 30% of estimatedenergy needs) in obese women with GDMmay improve glycemic control withoutketonemia and reduce maternal weightgain. Insufficient data are available to de-termine how such diets affect perinataloutcomes. Daily food records, weeklyweight checks, and ketone testing can beused to determine individual energy re-quirements and whether a woman is un-dereating to avoid insulin therapy.

The amount and distribution of car-

bohydrate should be based on clinicaloutcome measures (hunger, plasma glu-cose levels, weight gain, ketone levels),but a minimum of 175 g carbohydrate/day should be provided (22). Carbohy-drate should be distributed throughoutthe day in three small- to moderate-sizedmeals and two to four snacks. An eveningsnack may be needed to prevent acceler-ated ketosis overnight. Carbohydrate isgenerally less well tolerated at breakfastthan at other meals.

Regular physical activity can help

lower fasting and postprandial plasmaglucose concentrations and may be usedas an adjunct to improve maternal glyce-mia. If insulin therapy is added to MNT,maintaining carbohydrate consistency atmeals andsnacks becomes a primary goal.

Although most women with GDM re-vert to normal glucose tolerance postpar-tum, they are at increased risk of GDM insubsequent pregnancies and type 2 diabe-tes later in life. Lifestyle modifications af-ter pregnancy aimed at reducing weightand increasing physical activity are rec-ommended, as they reduce the risk ofsubsequent diabetes (26,91). Breast-feeding is recommended for infants ofwomen with preexisting diabetes orGDM; however, successful lactation re-quires planning and coordination of care(92). In most situations, breast-feedingmothers require less insulin because ofthe calories expended with nursing. Lac-tating women have reported fluctuationsin blood glucose related to nursing ses-sions, often requiring a snack containingcarbohydrate before or during breast-feeding (92).

Nutrition interventions for olderadults with diabetes

Recommendations Obese older adults with diabetes may

benefit from modest energy restrictionand an increase in physical activity; en-ergy requirement may be less than for a

younger individual of a similar weight.(E)

A daily multivitamin supplement maybe appropriate, especially for thoseolder adults with reduced energy in-take. (C)

The American Geriatrics Society em-phasizes the importance of MNT for olderadults with diabetes. For obese individu-als, a modest weight loss of 510% ofbody weight may be indicated (93,94).However, an involuntary gain or loss of

10 lb or 10% of body weight in

6months should be addressed in the MNTevaluation (1,95,96). Physical activity isneededto attenuateloss of lean body massthat can occur with energy restriction. Ex-ercise training can significantly reduce thedecline in maximal aerobic capacity thatoccurs with age, improve risk factors foratherosclerosis, slow the age-related de-cline in lean body mass, decrease centraladiposity, and improve insulin sensitivi-tyall potentially beneficial for the olderadult with diabetes (89,97). However, ex-ercise can also pose potential risks such as

cardiac ischemia, musculoskeletal inju-ries, and hypoglycemia in patients treatedwith insulin or insulin secretagogues.

NUTRITIONRECOMMENDATIONS FORCONTROLLING DIABETESCOMPLICATIONS(TERTIARY PREVENTION)

Microvascular complications

Recommendations

Reduction of protein intake to 0.81.0g kg body wt1 day1 in individualswith diabetes and the earlier stages ofchronic kidney disease (CKD) and to0.8g kg body wt1 day1 in the laterstages of CKD may improve measuresof renal function (urine albumin excre-tion rate, glomerular filtration rate) andis recommended. (B)

MNT that favorably affects cardiovas-cular risk factors may also have afavorable effect on microvascularcomplications such as retinopathy andnephropathy. (C)

Position Statement



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Progression of diabetes complicationsmay be modified by improving glycemiccontrol, lowering blood pressure, and,potentially, reducing protein intake. Nor-mal protein intake (1520% of energy)does not appear to be associated with riskof developing diabetic nephropathy (1),but the long-term effect on development

of nephropathy of dietary protein intake20% of energy has not been deter-mined. In several studies of subjects withdiabetes and microalbuminuria, urinaryalbumin excretion rate and decline in glo-merular filtration were favorably influ-enced by reduction of protein intake to0.81.0 g kg body wt1 day1 (seePROTEIN IN DIABETES MANAGEMENT section)(98101). Although reduction of proteinintake to 0.8 g kg body wt1 day1

was prescribed, subjects who were notable to achieve this level of reduction also

showed improvements in renal function(99,100).In individuals with diabetes and mac-

roalbuminuria, reducing protein from allsources to 0.8 g kg body wt1 day1

has been associated with slowing the de-cline in renal function (1,102); however,such reductions in protein need to main-tain good nutritional status in patientswith chronic renal failure (103). Al-though several studies have explored thepotential benefit of plant proteins in placeof animal proteins and specific animalproteins in diabetic individuals with mi-

croalbuninuria, the data are inconclusive(1,104).

Observational data suggest that dys-lipidemia may increase albumin excretionand the rate of progression of diabetic ne-phropathy (105). Elevation of plasmacholesterol in both type 1 and 2 diabeticsubjects and plasma triglycerides in type2 diabetic subjects were predictors of theneed for renal replacement therapy (106).

Whereas these observations do not con-firm that MNT will affect diabetic ne-phropathy, MNT designed to reduce the

risk for CVD may have favorable effects onmicrovascular complications of diabetes.

Treatment and management of CVDrisk

Recommendations Target A1C is as close to normal as pos-

sible without significant hypoglycemia.(B)

For patients with diabetes at risk forCVD, diets high in fruits, vegetables,whole grains, and nuts may reduce therisk. (C)

For patients with diabetes and symp-tomatic heart failure, dietary sodiumintake of2,000 mg/day may reducesymptoms. (C)

In normotensive and hypertensive indi-viduals, a reduced sodium intake (e.g.,2,300 mg/day) with a diet high in fruits,vegetables, and low-fat dairy products

lowers blood pressure. (A) In most individuals, a modest amount

of weight loss beneficially affects bloodpressure. (C)

In the EDIC (Epidemiology of Diabe-tes Interventions and Complications)study, the follow-up of the DCCT (Diabe-tes Control and Complications Trial), in-tensive treatment of type 1 diabeticsubjects during the DCCT study periodimproved glycemic control and signifi-cantly reduced the risk of the combined

end point of cardiovascular death, myo-cardial infarction, and stroke (107). Ad-justment for A1C explained most of thetreatment effect. The risk reductions ob-tained with improved glycemia exceededthose that have been demonstrated forother interventions such as cholesteroland blood pressure reductions. Observa-tional data from the UKPDS suggest thatCVD risk in type 2 diabetes is also pro-portionate to the level of A1C elevation(107a).

There are no large-scale randomizedtrials to guide MNT recommendations for

CVD risk reduction in individuals withtype 2 diabetes. However, because CVDrisk factors are similar in individuals withand without diabetes, benefits observedin nutrition studies in the general popu-lation are probably applicable to individ-uals with diabetes. The previous sectionon dietary fat addresses the need to re-duce intake of saturated and trans fattyacids and cholesterol.

Hypertension, which is predictive ofprogression of micro- as well as macro-vascular complications of diabetes, can be

prevented and managed with interven-tions including weight loss, physical ac-tivity, moderation of alcohol intake, anddiets such as DASH (Dietary Approachesto Stop Hypertension). The DASH dietemphasized fruits, vegetables, and low-fatdairy products; included whole grains,poultry, fish, and nuts; and was reducedin fats, red meat, sweets, and sugar-containing beverages (7,108,109). Theeffects of lifestyle interventions on hyper-tension appear to be additive.

Reduction in blood pressure in peo-ple with diabetes can occur with a modest

amount of weight loss, although there isgreat variability in response (1,7). Regularaerobic physical activity, such as briskwalking, has an antihypertensive effect(7). Although chronic excessive alcoholintake is associated with an increased riskof hypertension, light to moderate alcoholconsumption is associated with reduc-

tions in blood pressure (7).Heart failure and peripheral vascular

disease are common in individuals withdiabetes, but little is known about the roleof MNT in treating these complications.Nutrition recommendations from the

American College of Physicians/AmericanHeart Association suggest moderate so-dium restriction (2,000 mg/day) for pa-tients with structural heart disease orsymptomatic heart failure (110). Alcoholintake is discouraged in patients at highrisk for heart failure.

NUTRITIONINTERVENTIONS FORACUTE COMPLICATIONSAND SPECIALCONSIDERATIONS FORPATIENTS WITHCOMORBIDITIES IN ACUTEAND CHONIC CAREFACILITIES

Hypoglycemia

Recommendations Ingestion of 1520 g glucose is the pre-

ferred treatment for hypoglycemia, al-though any form of carbohydrate thatcontains glucose may be used. (A)

The response to treatment of hypogly-cemia should be apparent in 1020min; however, plasma glucose shouldbe tested again in 60 min, as addi-tional treatment may be necessary. (B)

In individuals taking insulin or insu-lin secretagogues, changes in food intake,physical activity,and medication can con-

tribute to the development of hypoglyce-mia. Treatment of hypoglycemia (plasmaglucose70 mg/dl) requires ingestion ofglucose or glucose-containing foods. Theacute glycemic response correlates betterwith the glucose content than with thecarbohydrate content of the food (1).

With insulin-induced hypoglycemia, 10 goral glucose raises plasma glucose levelsby 40 mg/dl over 30 min, while 20 goral glucose raises plasma glucose levelsby 60 mg/dl over 45 min. In each case,glucose levels often begin to fall 60 minafter glucose ingestion (111).




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Table 3Major nutrition recommendations and interventions

Effectiveness of MNT

Individuals who have pre-diabetes or diabetes should receive individualized MNT; such therapy is best provided by a registered dietitian

familiar with the components of diabetes MNT. (B)

Nutrition counseling should be sensitive to the personal needs, willingness to change, and ability to make changes of the individual with

pre-diabetes or diabetes. (E)

Energy balance, overweight, and obesity

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

loss is recommended for all such individuals who have or are at risk for diabetes. (A)

For weight loss, either low-carbohydrate or low-fat calorie-restricted diets may be effective in the short term (up to 1 year). (A)

For patients on low-carbohydrate diets, monitor lipid profiles, renal function, and protein intake (in those with nephropathy), and adjusthypoglycemic therapy as needed. (E)

Physical activity and behavior modification are important components of weight loss programs and are most helpful in maintenance ofweight loss. (B)

Weight loss medications may be considered in the treatment of overweight and obese individuals with type 2 diabetes and can helpachieve a 510% weight loss when combined with lifestyle modification. (B)

Bariatric surgery may be considered for some individuals with type 2 diabetes and BMI 35 kg/m2 and can result in markedimprovements in glycemia. The long-term benefits and risks of bariatric surgery in individuals with pre-diabetes or diabetes continue to be

studied. (B)

Preventing diabetes (primary prevention) Among individuals at high risk for developing type 2 diabetes, structured programs that emphasize lifestyle changes that include

moderate weight loss (7% body weight) and regular physical activity (150 min/week), with dietary strategies including reduced caloriesand reduced intake of dietary fat, can reduce the risk for developing diabetes and are therefore recommended. (A)

Individuals at high risk for type 2 diabetes should be encouraged to achieve the USDA recommendation for dietary fiber (14 gfiber/1,000 kcal) and foods containing whole grains (one-half of grain intake). (B)

There is not sufficient, consistent information to conclude that lowglycemic load diets reduce the risk for diabetes. Nevertheless, low

glycemic index foods that are rich in fiber and other important nutrients are to be encouraged. (E)

Observational studies report that moderate alcohol intake may reduce the risk for diabetes, but the data do not support recommending

alcohol consumption to individuals at risk of diabetes. (B)

No nutrition recommendation can be made for preventing type 1 diabetes. (E)

Although there are insufficient data at present to warrant any specific recommendations for prevention of type 2 diabetes in youth, it isreasonable to apply approaches demonstrated to be effective in adults, as long as nutritional needs for normal growth and development are

maintained. (E)

Controlling diabetes (secondary prevention)Carbohydrate in diabetes management

A dietary pattern that includes carbohydrate from fruits, vegetables, whole grains, legumes, and low-fat milk is encouraged for goodhealth. (B)

Monitoring carbohydrate, whether by carbohydrate counting, exchanges, or experienced-based estimation, remains a key strategy inachieving glycemic control. (A)

The use of glycemic index and load may provide a modest additional benefit over that observed when total carbohydrate is consideredalone. (B)

Sucrose-containing foods can be substituted for other carbohydrates in the meal plan or, if added to the meal plan, covered withinsulin or other glucose-lowering medications. Care should be taken to avoid excess energy intake. (A)

As for the general population, people with diabetes are encouraged to consume a variety of fiber-containing foods. However, evidenceis lacking to recommend a higher fiber intake for people with diabetes than for the population as a whole. (B)

Sugar alcohols and nonnutritive sweeteners are safe when consumed within the daily intake levels established by the FDA. (A)Fat and cholesterol in diabetes management

Limit saturated fat to 7% of total calories. (A)

Intake oftrans fat should be minimized. (E)

In individuals with diabetes, lower dietary cholesterol to 200 mg/day. (E)

Two or more servings of fish per week (with the exception of commercially fried fish filets) provide n-3 polyunsaturated fatty acids

and are recommended. (B)Protein in diabetes management

For individuals with diabetes and normal renal function, there is insufficient evidence to suggest that usual protein intake (1520% of

energy) should be modified. (E)

In individuals with type 2 diabetes, ingested protein can increase insulin response without increasing plasma glucose concentrations.

Therefore, protein should not be used to treat acute or prevent nighttime hypoglycemia. (A)

Continued on following page

Position Statement



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Table 3Continued

High-protein diets are not recommended as a method for weight loss at this time. The long-term effects of protein intake 20% of

calories on diabetes management and its complications are unknown. Although such diets may produce short-term weight loss andimproved glycemia, it has not been established that these benefits are maintained long term, and long-term effects on kidney function

for persons with diabetes are unknown. (E)Alcohol in diabetes management

If adults with diabetes choose to use alcohol, daily intake should be limited to a moderate amount (one drink per day or less for

women and two drinks per day or less for men). (E) To reduce risk of nocturnal hypoglycemia in individuals using insulin or insulin secretagogues, alcohol should be consumed withfood. (E)

In individuals with diabetes, moderate alcohol consumption (when ingested alone) has no acute effect on glucose and insulinconcentrations but carbohydrate coingested with alcohol (as in a mixed drink) may raise blood glucose. (B)

Micronutrients in diabetes management

There is no clear evidence of benefit from vitamin or mineral supplementation in people with diabetes (compared with the generalpopulation) who do not have underlying deficiencies. (A)

Routine supplementation with antioxidants, such as vitamins E and C and carotene, is not advised because of lack of evidence ofefficacy and concern related to long-term safety. (A)

Benefit from chromium supplementation in individuals with diabetes or obesity has not been clearly demonstrated and therefore cannot be recommended. (E)

Nutrition interventions for type 1 diabetes

For individuals with type 1 diabetes, insulin therapy should be integrated into an individuals dietary and physical activity pattern. (E)

Individuals using rapid-acting insulin by injection or an insulin pump should adjust the meal and snack insulin doses based on thecarbohydrate content of the meals and snacks. (A)

For individuals using fixed daily insulin doses, carbohydrate intake on a day-to-day basis should be kept consistent with respect totime and amount. (C)

For planned exercise, insulin doses can be adjusted. For unplanned exercise, extra carbohydrate may be needed. (E)Nutrition interventions for type 2 diabetes

Individuals with type 2 diabetes are encouraged to implement lifestyle modifications that reduce intakes of energy, saturated and transfatty acids, cholesterol, and sodium and to increase physical activity in an effort to improve glycemia, dyslipidemia, and blood pressure.

(E)

Plasma 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. (E)Nutrition interventions for pregnancy and lactation with diabetes

Adequate energy intake that provides appropriate weight gain is recommended during pregnancy. Weight loss is not recommended;

however, for overweight and obese women with GDM, modest energy and carbohydrate restriction may be appropriate. (E) Ketonemia from ketoacidosis or starvation ketosis should be avoided. (C)

MNT for GDM focuses on food choices for appropriate weight gain, normoglycemia, and absence of ketones. (E)

Because GDM is a risk factor for subsequent type 2 diabetes, after delivery, lifestyle modifications aimed at reducing weight andincreasing physical activity are recommended. (A)

Nutrition interventions for older adults with diabetes

Obese older adults with diabetes may benefit from modest energy restriction and an increase in physical activity; energy requirement

may be less than for a younger individual of a similar weight. (E)

A daily multivitamin supplement may be appropriate, especially for those older adults with reduced energy intake. (C)

Treating and controlling diabetes complications (tertiary prevention)Microvascular complications

Reduction of protein intake to 0.81.0 g kg body wt1 day1 in individuals with diabetes and the earlier stages of CKD and to 0.8 g

kg body wt1 day1 in the later stages of CKD may improve measures of renal function (urine albumin excretion rate, glomerular

filtration rate) and is recommended. (B) MNT that favorably affects cardiovascular risk factors may also have a favorable effect on microvascular complications such as

retinopathy and nephropathy. (C)Treatment and management of CVD risk

Target A1C is as close to normal as possible without significant hypoglycemia. (B)

For patients with diabetes at risk for CVD, diets high in fruits, vegetables, whole grains, and nuts may reduce the risk. (C)

For patients with diabetes and symptomatic heart failure, dietary sodium intake of2,000 mg/day may reduce symptoms. (C)

In normotensive and hypertensive individuals, a reduced sodium intake (e.g., 2,300 mg/day) with a diet high in fruits, vegetables, and

low-fat dairy products lowers blood pressure. (A)

In most individuals, a modest amount of weight loss beneficially affects blood pressure. (C)

Continued on following page




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Although pure glucose may be thepreferred treatment, any form of carbohy-drate that contains glucose will raiseblood glucose (111). Adding protein tocarbohydrate does not affect the glycemicresponse and does not prevent subse-quent hypoglycemia. Adding fat, how-ever, may retard and then prolong theacute glycemic response. During hypo-glycemia, gastric-emptying rates are twice

as fast as during euglycemia and are sim-ilar for liquid and solid foods.

Acute illness

Recommendations During acute illnesses, insulin and oral

glucose-lowering medications shouldbe continued. (A)

During acute illnesses, testing ofplasma glucose and ketones, drinkingadequate amounts of fluids, and ingest-ing carbohydrate are all important. (B)

Acute illnesses can lead to the devel-opment of hyperglycemia and, in individ-uals with type 1 diabetes, ketoacidosis.During acute illnesses, with the usual ac-companying increases in counterregula-tory hormones, the need for insulin andoral glucose-lowering medications con-tinues and often is increased. Testingplasma glucose and ketones, drinking ad-equate amounts of fluid, and ingestingcarbohydrate, especially if plasma glucoseis 100 mg/dl, are all important duringacute illness. In adults, ingestion of 150

200 g carbohydrate daily (4550 g every34 h) should be sufficient to preventstarvation ketosis (1).

Patients with diabetes in acutehealth care facilities

Recommendations Establishing an interdisciplinary team,

implementation of MNT, and timely di-

abetes-specific discharge planning im-proves thecare of patients with diabetesduring and after hospitalizations. (E)

Hospitals should consider implement-ing a diabetes meal-planning systemthat provides consistency in the carbo-hydrate content of specific meals. (E)

Hyperglycemia in hospitalized pa-tients is common and represents an im-portant marker of poor clinical outcomeand mortality in both patients with andwithout diabetes (112). Optimizing glu-

cose control in these patients is associatedwith better outcomes (113). An interdis-ciplinary team is needed to integrateMNTinto the overall management plan(114,115). Diabetes nutrition self-management education, although poten-tially initiated in the hospital, is usuallybest provided in an outpatient or homesetting where the individual with diabetesis better able to focus on learning needs(114,115).

There is no single meal planning sys-tem that is ideal for hospitalized patients.However, it is suggested that hospitals

consider implementing a consistent-carbohydrate diabetes meal-planning sys-tem (114,115). This systems uses mealplans without a specific calorie level butconsistency in the carbohydrate contentof meals. The carbohydrate contents ofbreakfast, lunch, dinner, and snacks mayvary, but the day-to-day carbohydratecontent of specific meals and snacks iskept constant (114,115). It is recom-

mended that the term ADA diet nolonger be used, since the ADA no longerendorses a single nutrition prescription orpercentages of macronutrients.

Special nutrition issues include liquiddiets, surgical diets, catabolic illnesses,and enteral or parenteral nutrition(114,115). Patients requiring clear or fullliquid diets should receive200 g carbo-hydrate/day in equally divided amountsat meal and snack times. Liquids shouldnot be sugar free. Patients require carbo-hydrate and calories, and sugar-free liq-uids do not meet these nutritional needs.For tube feedings, either a standard en-teral formula (50% carbohydrate) or alowercarbohydrate content formula(3340% carbohydrate) may be used.Calorie needs for most patients are in therange of 2535 kcal/kg every 24 h. Caremust be taken not to overfeed patientsbecause this can exacerbate hyperglyce-mia. After surgery, food intake should beinitiated as quickly as possible. Progres-sion from clear liquids to full liquids tosolid foods should be completed as rap-idly as tolerated.

Table 3Continued

Hypoglycemia

Ingestion of 1520 g glucose is the preferred treatment for hypoglycemia, although any form of carbohydrate that contains glucose

may be used. (A)

The response to treatment of hypoglycemia should be apparent in 1020 min; however, plasma glucose should be tested again in 60

min, as additional treatment may be necessary. (B)Acute illness

During acute illnesses, insulin and oral glucose-lowering medications should be continued. (A)

During acute illnesses, testing of plasma glucose and ketones, drinking adequate amounts of fluids, and ingesting carbohydrate are all

important. (B)Acute health care facilities

Establishing an interdisciplinary team, implementation of MNT, and timely diabetes-specific discharge planning improves the care ofpatients with diabetes during and after hospitalizations. (E)

Hospitals should consider implementing a diabetes meal-planning system that provides consistency in the carbohydrate content ofspecific meals. (E)

Long-term care facilities

The imposition of dietary restrictions on elderly patients with diabetes in long-term care facilities is not warranted. Residents with

diabetes should be served a regular menu, with consistency in the amount and timing of carbohydrate. (C)

An interdisciplinary team approach is necessary to integrate MNT for patients with diabetes into overall management. (E)

There is no evidence to support prescribing diets such as no concentrated sweets or no sugar added. (E)

In the institutionalized elderly, undernutrition is likely and caution should be exercised when prescribing weight loss diets. (B)

Position Statement



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Patients with diabetes in long-termcare facilities

Recommendations The imposition of dietary restrictions

on elderly patients with diabetes inlong-term care facilities is not war-ranted. Residents with diabetes should

be served a regular menu, with consis-tency in the amount and timing of car-bohydrate. (C)

An interdisciplinary team approach isnecessary to integrate MNT for patientswith diabetes into overall management.(E)

There is no evidence to support pre-scribing diets such as no concentratedsweets or no sugar added. (E)

In the institutionalized elderly, under-nutrition is likely and caution shouldbe exercised when prescribing weight

loss diets. (B)

Although the prevalence of undiag-nosed diabetes in elderly nursing homeresidents is high, not all of such individ-uals require pharmacologic therapy(115,116). Older residents with diabetesin nursing homes tend to be underweightrather than overweight (114). Low bodyweight has been associated with greatermorbidity and mortality in this popula-tion (114,115). Experience has shownthat residents eat better when they aregiven less restrictive diets (115,116). Spe-

cialized diabetic diets do not appear to besuperior to standard diets in such settings(117,118). Meal plans such as no concen-trated sweets, no sugar added, low sugar,and liberal diabetic diet also are no longerappropriate. These diets do not reflectcurrent diabetes nutrition recommenda-tions and unnecessarily restrict sucrose.(These types of diets are more likely inlong-term care facilities than acute care.)Making medication changes to controlglucose, lipids, and blood pressure ratherthan implementing food restrictions can

reduce the risk of iatrogenic malnutrition.The specific nutrition interventions rec-ommended will depend on a variety offactors, including age, life expectancy, co-morbidities, and patient preferences(119).

SUMMARY: NUTRITIONRECOMMENDATIONS ANDINTERVENTIONS FORDIABETES Major nutrition recom-mendations and interventions for diabe-tes are listed in Table 3. Monitoring ofmetabolic parameters, including glucose,

A1C, lipids, blood pressure, body weight,andrenal function is essential to assess theneed for changes in therapy and to ensuresuccessful outcomes. Many aspects ofMNT require additional research.

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