Nutrition Recommendations and Principles for People with Diabetes 
Mellitus

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[07August96]
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from Diabetes Care, Volume 17, Nummber 5, May 1994

Medical nutrition therapy is integral to total diabetes care and 
management. Although adherence to nutrition and meal planning 
principles is one of the most challenging aspects of diabetes care, 
nutrition therapy is an essential component of successful diabetes 
management.

Achieving nutrition-related goals requires a coordinated team effort 
that includes the person with diabetes. Because of the complexity of 
nutrition issues, it is recommended that a registered dietitian, 
knowledgeable and skilled in implementing current principles and 
recommendations for diabetes, be a member of the treatment team.

Effective self-management training requires an individualized approach,
appropriate for the personal lifestyle and diabetes management goals of
the individual with diabetes. Monitoring of glucose and glycated 
hemoglobin, lipids, blood pressure, and renal status is essential to 
evaluate nutrition-related outcomes. If goals are not met, changes must 
be made in the overall diabetes care and management plan.

Nutrition assessment is used to determine what the individual with 
diabetes is able and willing to do. A major consideration is the 
likelihood of adherence to nutrition recommendations. To facilitate 
adherence, sensitivity to cultural, ethnic, and financial 
considerations is of prime importance.

This paper reflects scientific nutrition and diabetes knowledge as of 
1994. However, there are limited published data for some recommendations 
and, under these circumstances, recommendations are based on clinical 
experiences and consensus. This position paper is based on the 
concurrent technical review paper, which discusses published research 
and issues that remian unresovled. (1).

Goals of Medical Nutrition Therapy - 

Although the overall goal of nutrition therapy is to assist people with 
diabetes in making changes in nutrition and exercise habits leading to 
improved metabolic control, there are additional specific goals:

1. Maintenance of as near-normal blood glucose levels as possible by 
   balancing food intake with insulin (either endogenous or exogenous) 
   or oral glucose-lowering medications and activity levels.
2. Achievement of optimal serum lipid levels.
3. Provision of adequate calories for maintaining or attaining 
   reasonable weights for adults, normal growth and development rates in 
   children and adolescents, increased metabolic needs during pregnancy 
   and lactation, or recovery from catabolic illnesses. Reasonable 
   weight is defined as the weight an individual and health care 
   provider acknowledge as achievable and maintainable, both short- and 
   long-term. This may not be the same as the traditionally defined 
   desirable or ideal body weight.
4. Prevention and treatment of the acute complications of 
   insulin-treated diabetes such as hypoglycemia, short-term illneses, 
   and exercise-related problems, and of the long-term complications of 
   diabetes such as renal disease, autonomic neuropathy, hypertension, 
   and cardiovascular disease.
5. Improvement of overall health through optimal nutrition. _Dietary 
   Guidelines for Americans_ (2) and the _Food Guide Pyramid_ (3) 
   summarize and illustrate nutritional guidelines and nutrient needs 
   for all healthy Americans, and can be used by people with diabetes 
   and their family members.

Nutrition Therapy and Type I Diabetes - 

A meal plan based on the individual's usual food intake should be 
determined and used as a basis for integrating insulin therapy into the 
usual eating and exercise patterns. It is recommended that individuals 
using insulin therapy eat at consistent times synchronized with the 
time-action of the insulin preparation used. Further, individuals need 
to monitor blood glucose levels and adjust insulin doses for the amount 
of food usually eaten. Intensified insulin therapy, such as multiple 
daily injections or use of an inuslin pump, allows considerable 
flexibility in when and what individuals eat. With intensified therapy, 
insulin regimens should be integrated with lifestyle and adjusted for 
deviations from usual eating and exercise habits.

Nutrition Therapy and Type II Diabetes - 

The emphasis for medical nutrition therapy in type II diabetes should be 
placed on achieving glucose, lipid, and blood pressure goals. Weight 
loss and hypocaloric diets usually improve short-term glycemic levels 
and have the potential to increase long-term metabolic control. However, 
traditional dietary strategies, and even very-low-calorie diets, have 
usually not been effective in achieving long-term weight loss; 
therefore, emphasis should be placed instead on glucose and lipid goals. 
Although weight loss is desirable, and some individuals are able to lose 
and maintain weight loss, several additional strategies can be 
implemented to improve metabolic control. There is no one proven 
strategy or method that can be uniformly recommended.

An initial strategy is improvement in food choices, as illustrated by 
_Dietary Guidelines for Americans_ and the _Food Guide Pyramid_. A 
nutritionally adequate meal plan with a reduction of total fat, 
especially saturated fats, can be employed. Spacing meals (spreading 
nutrient intake throughout the day) is another strategy that can be 
adopted. Mild to moderate weight loss (5-10 kg [10-20 pounds]) has been 
shown to improve diabetes control, even if desirable body weight is not 
achieved. Weight loss is best attempted by a moderate decrease in 
calories and an increase in caloric expenditures. Moderate caloric 
restriction (250-500 calores less than average daily intake) is 
recommended.

Regular exercise and learning new behaviors and attitudes can help 
facilitate long-term lifestyle changes. Monitoring blood glucose 
levels, glycated hemoglobin, lipids, and blood pressure is essential. 
However, if metabolic control has not improved after employment of 
better nutrition and regular exercise, an oral glucose-lowering 
medication or insulin may be needed.

Many individuals with refractory obesity may have limited success with 
the above strategies. Newer pharmacological agents, i.e., the 
serotonergic appetite suppressants, as well as gastric reduction surgery 
(for people with a body mass index of >35kg/m2) may prove to be 
potentially beneficial to this group. Studies on the long-term efficacy 
and safety of these methods are, however, unavailable.

Protein - 

There is limited scientific data upon which to establish firm nutritional
recommendations for protein intake for individuals with diabetes. At the
present time, there is insufficient evidence to support protein intakes either
higher or lower than average protein intake for the general population. For
people with diabetes, this translates into ~10-20% of the daily caloric intake
from protein. Dietary protein should be derived from both animal and vegetable
sources.

With the onset of nephropathy, lower intakes or protein should be 
considered. A protein intake similar to the adult Recommended Dietary 
Allowance (0.8g kg body wt day), ~10% of daily calories, is sufficiently 
restrictive and is recommended for individuals with evidence of 
nephropathy.

Total Fat - 

If dietary protein constributes 10-20% of the total caloric content of 
the diet, then 80-90% of calories remain to be distributed between 
dietary fat and carbohydrate. Less than 10% of these calories should be 
from saturated fats and up to 10% calories from polyunsaturated fats, 
leaving 60-70% of the total calories from monounsaturated fats and 
carbohydrates. The distribution of calories from fat and carbohydrate 
can vary and be individualized based on the nutrition assessment and
treatment goals.

The recommended percentage of calories from fat is dependent on desired 
glucose, lipid, and weight outcomes. For individuals who have normal 
lipid levels and maintain a reasonable weight (and for normal growth and 
development in children and adolescents) the _Dietary Guidelines for 
Americans_ recommendations of 30% or less of the calories from total 
fat and <10% of calories from saturated fat can be implemented.

If obesity and weight loss are the primary issues, a reduction in 
dietary fat intake is an efficient way to reduce caloric intake and
weight, particularly when combined with exercise.

If elevated low-density lipoprotein (LDL) cholesterol is the primary 
problem, the Natioanl Cholesterol Education Program Step II diet 
guidelines, in which <7% of total calories are from saturated fat, 
less-than-or-equal-to 30% of the calories are from total fat, and 
dietary cholesterol is <200 mg/day, should be implemented.

If elevated triglycerides and very low density lipoprotein cholesterol 
are the primary problems, one approach that may be beneficial, other 
than weight loss and increased physical activity, is a moderate increase 
in monounsaturated fat intake, with <10% of calories each from saturated 
and polyunsaturated fast, monounsaturated fats up to 20% of calories, 
and a more moderate intake of carbohydrate. However, in obese 
individuals, the increase in fat intake may perpetuate or aggravate the 
obesity. In addition, patients with triglyceride levels >1,000 mg/dl may 
require reduction of all types of dietary fat to reduce levels of plasma 
dietary fat in the form of chylomicrons.

Monitoring glycemic and lipid status and body weight, on any diet, is 
essential to assess the effectiveness of the nutrition recommendations.

Saturated Fat and Cholesterol - 

A reduction in saturated fat and cholesterol consumption is an 
important goal to reduce the risk of cardiovascular disease (CVD). 
Diabetes is a strong independent risk factor for CVD, over and above 
the adverse effects of an elevated serum cholesterol. Therefore, <10% 
of the daily calories should be from saturated fats, and dietary 
cholesterol should be limited to 300 mg or less daily. However, even 
these recommendations must be incorporated with consideration of an 
individual's cultural and ethnic background.

Polyunsaturated fats of the omega-3 series are provided naturally in 
fish and other seafood, and the intake of these foods need not be 
curtailed in people iwth diabetes mellitus.

Carbohydrate and Sweeteners - 

The percentage of calories from carbohydrate will also vary, and is 
individualized based on the patient's eating habits and glucose and 
lipid goals. For most of this century, the most widely held belief 
about the dietary treatment of diabetes has been that "simple" sugars 
should be avoided and replaced with complex carbohydrates. This belief 
appears to be based on the assumption that sugars are more rapidly 
digested and absorbed than are starches and thereby aggravate 
hyperglycemia to a greater degree. There is, however, very little 
scientific evidence that supports this assumption. Fruits and milk have 
been shown to have a lower glycemic response than most starches, and 
sucrose produces a glycemic response simlar to that of bread, rice, and 
potatoes. Although various starches do have different glycemic 
responses, from a clinical perspective first priority should be given 
to the total amount of carbohydrate consumed rather than the source of 
the carbohydrate.

Sucrose - 

Scientific evidence has shown that the use of sucrose as part of the 
meal plan does not impair blood glucose control in individuals with 
type I or type II diabetes. Sucrose and sucrose-containing foods must 
be substituted for other carbohydrates and foods and not simply added 
to the meal plan. In making such substitutions, the nutrient content of 
concentrated sweets and sucrose-containing foods, as well as the 
presence of other nutriets frequently ingested with sucrose such as 
fat, must be considered.

Fructose - 

Dietary fructose produces a smaller rise in plasma glucose than 
isocaloric amounts of sucrose and most starchy carbohydrates. In that 
regard, fructose may offer an advantage as a sweetening agent in the 
diabetic diet. However, because of potential adverse effects of large 
amounts of fructose (i.e., double the usual intake [20% of calories]) 
on serum cholesterol and LDL cholesterol, fructose may have no overall 
advantage as a sweetening agent in the diabetic diet. Although people 
with dyslipidemia should avoid consuming large amounts of fructose, 
there is no reason to recommend that people avoid consumption of 
fruits and vegetables, in which fructose occurs naturally, or moderate 
consumption of fructose-sweetened foods.

Other Nutritive Sweeteners - 

Nutritive sweeteners other than sucrose and fructose include corn 
sweeteners such as corn syrup, fruit juice or fruit juice concentrate, 
honey, molasses, dextrose, and maltose. There is no evidence that these 
sweeteners have any significant advantage or disadvantage over sucrose 
in terms of improvement in caloric content or glycemic response.

Nonnutritive Sweeteners - 

Saccharin, aspartame, and acesulfame K are approved for use by the Food 
and Drug Administration (FDA) in the United States. The FDA also 
determines an acceptable daily intake for approved food additives, 
including nonnutritive sweeteners. Nonnutritive sweeteners approved 
by the FDA are safe to consume by all people with diabetes.

Fiber - 

Dietary fiber may be beneficial in treating or preventing several 
gastrointestinal disorders, including colon cancer, and large amounts 
of soluble fiber have a beneficial effect on serum lipids. There is no 
reason to believe that people with diabetes would be more or less 
amenable to these effects than those without diabetes. Although 
selected soluble fibers are capable of delaying glucose absorption from 
the small intestine, the effect of dietary fiber on glycemic control is 
probably insignificant. Therefore, fiber intake recommendations for 
people with diabetes are the same as for the general population. Daily 
consumption of a diet containing 20-35g dietary fiber from a wide 
variety of food sources is recommended.

Sodium -

People differ greatly in their sensitivity to sodium and its effect on 
blood pressure. Because it is impractical to assess individual sodium 
sensitivity, intake recommendations for people with diabetes are the 
same as for the general population. Some health authorities recommend 
no more than 3,000 mg/day of sodium for the general population, while 
other authorities recommend no more than 2,400 mg/day. For people with 
mild to moderate hypertension, 2,400 mg or less per day of sodium is 
recommended.

Alcohol -

The same precautions regarding the use of alcohol that apply to the 
general public also apply to people with diabetes. Under normal 
circumstances, however, blood glucose levels will not be affected by 
moderate use of alcohol when diabetes is well controlled. For people 
using insulin, less-than-or-equal-to 2 alcoholic beverages (1 alcoholic 
beverage = 12 oz. beer, 5 oz. wine, or 1.5 oz. distilled spirits) can 
be ingested with and in addition to the usual meal plan.

Special considerations for further modification of alcohol intake 
include the following. Abstention from alcohol should be advised for 
people with a history of alcohol abuse or during pregnancy. Alcohol may 
increase the risk for hypoglycemia in people treated with insulin or 
sulfonylureas. If alcohol is consumed by such people, it should only 
be ingested with a meal. Reduction of or abstention from alcohol intake 
may be advisable for people with diabetes with other medical problems 
such as pancreatitis, dyslipidemia, or neuropathy. When calories from 
alcohol need to be calculated as part of the total caloric intake, 
alcohol is best substituted for fat exchanges or fat calories (1 
alcoholic beverage = 2 fat exchanges).

Micronutrients: Vitamins and Minerals - 

When dietary intake is adequate, there is generally no need for 
additional vitamins and mineral supplementation for the majority of 
people with diabetes. Although there are theoretical reasons to 
supplement with antioxidants, there is little confirmatory evidence at 
present that such therapy has any benefits.

The only known circumstance in which chromium replacement has any 
beneficial effect on glycemic control is for people who are chromium 
deficient as a result of long-term chromium-deficient parenteral 
nutrition. However, it appears that most people with diabetes are not 
chromium deficient and, therefore, chromium supplementation has no 
known benefit.

Similarly, although magnesium deficiency may play a role in insulin 
resistance, carbohydrate intolerance, and hypertension, the available 
data suggest that routine evaluation of serum magnesium levels is 
recommended only in patients at high risk for magnesium deficiency. 
Levels of magnesium should be repleted only if hypomagnesium can be 
demonstrated.

Potassium loss may be sufficient to warrant dietary supplementation in 
patients taking diuretics. Hyperkalemia sufficient to warrant dietary 
potassium restriction may occur in patients with renal insufficiency or 
hyporeninemic hypoaldosteronism or in patients taking angiotensin-
converting enzyme (ACE) inhibitors.

Pregnancy - 

Nutrition recommendations for women with preexisting and gestational 
diabetes mellitus should be based on a nutrition assessment. Monitoring 
blood glucose levels, urine ketones, appetite, and weight gain can be a 
guide to developing and evaluating an appropriate individualized meal 
plan and to making adjustments to the meal plan throughout pregnancy to 
ensure desired outcomes.

Summary - 

A historical perspective of nutrition recommendations is provided in 
Table 1. Today there is no ONE "diabetic" of "ADA" diet. The 
recommended diet can only be defined as a dietary prescription based on 
nutrition assessement and treatment goals.

Medical nutrition therapy for people with diabetes should be 
individualized, with consideration given to usual eating habits and 
other lifestyle factors. Nutrition recommendations are then developed 
to meet treatment goals and desired outcomes. Monitoring metabolic 
parameters including blood glucose, glycated hemoglobin, lipids, blood 
pressure, and body weight, as well as quality of life, is crucial to 
ensure successful outcomes.

References - 

1. Franz MJ, Horton ES, Bantle JP, Beebe CA, Brunzell JD, Coulston AM, 
   Henry RR, Hoogwerf BJ, Stacpoole PW: Nutrition principles of the
   management of diabetes and related complications (Technical review).
   _Diabetes Care_ 17:490-518, 1994.
2. U.S. Department of Agriculture, U.S. Department of Health and Human
   Services: _Nutrition and Your Health: Dietary Guidelines for
   Americans_. 3rd Ed. Hyattsville, MD. USDA's Human Nutrition 
   Information Service, 1990.
3. U.S. Department of Agriculture: _The Food Guide Pyramid_. 
   Hyattsville, MD. USDA's Human Nutition Information Service, 1992.

Table 1 - Historical perspective of nutrition recommendations


        Distribution of Calories
        ------------------------------------
Year    %Carbohydrate   %Protein        %Fat
____________________________________________
<1921        Starvation diets
1921    20              10              70
1950    40              20              40
1971    45              20              35
1986    up to 60        12-20           <30
1994    *               10-20           *,+
____________________________________________
*Based on nutritional assessment and treatment goals.
+Less than 10% of calories from saturated fats.