- ACRONYMS AND DEFINITIONS
- ADA - American Diabetes Association
- Carbs - Carbohydrates
- CVD - Cardiovascular disease
- DM1 - Type one diabetes
- DM2 - Type two diabetes
- GI - Glycemic index
- Macronutrients - Macronutrients are proteins, fats, and carbohydrates
- Micronutrients - Micronutrients are vitamins and minerals
- USDA - United States Department of Agriculture
- 1 kilogram = 2.2 pounds
- CALORIC REQUIREMENTS IN DM1 AND DM2
- Overview
- Diabetics should calculate their daily caloric requirements based on their weight and activity level
- Overweight patients with DM1 or DM2 should follow a calorie-restricted diet to lose weight
- ADA recommendations
- Weight loss (> 5%) achievable by the combination of reduction of calorie intake and lifestyle modification benefits overweight or obese adults with type 2 diabetes and also those with prediabetes. Intervention programs to facilitate weight loss are recommended.
- Weight loss can be attained with lifestyle programs that achieve a 500 – 750 kcal/day energy deficit or provide; 1,200 – 1,500 kcal/day for women and 1,500 – 1,800 kcal/day for men, adjusted for the individual’s baseline body weight
- For many obese individuals with type 2 diabetes, weight loss of at least 5% is needed to produce beneficial outcomes in glycemic control, lipids, and blood pressure clinical benefits of weight loss are progressive and more intensive weight loss goals (i.e., 15%) may be appropriate to maximize benefit depending on need, feasibility, and safety
- To achieve weight loss of > 5% in obese type 2 diabetics, short-term (3-month) interventions that use very low-calorie diets (≤ 800 kcal/day) and total meal replacements may be prescribed for carefully selected patients by trained practitioners in medical care settings with close medical monitoring. To maintain weight loss, such programs must incorporate long-term comprehensive weight-maintenance counseling. See low-calorie diet for remission of T2DM for more. [18]
- Links to more information
- Ideal body weight - information on determining ideal body weight
- Caloric requirements - information on determining individual caloric requirements
- Weight loss - information on losing weight
- Calorie calculator - calculate daily calorie requirements
- MACRONUTRIENT DISTRIBUTION IN DIABETES
- Overview
- Macronutrients are the components of food that supply calories
- Macronutrients include the following:
- USDA recommendations
| USDA recommended macronutrient distribution for the general public | |
|---|---|
| Macronutrient | % of total calories |
| Carbohydrates | 45 - 65% |
| Fats | 20 - 35% |
| Protein | 10 - 35% |
- ADA recommendations
- The ADA says the following about macronutrient distribution, "There is no single ideal dietary distribution of calories among carbohydrates, fats, and proteins for people with diabetes; therefore, macronutrient distribution should be individualized while keeping total calorie and metabolic goals in mind" [18]
- They go on to state that "reducing overall carbohydrate intake for individuals with diabetes has demonstrated the most evidence for improving glycemia and may be applied in a variety of eating patterns that meet individual needs and preferences. For select adults with type 2 diabetes not meeting glycemic targets or where reducing glucose-lowering medications is a priority, reducing overall carbohydrate intake with low- or very low carbohydrate eating plans is a viable approach"
- For specific macronutrient recommendations, see carbohydrates, protein, and fats below
- Summary
- A number of studies have compared macronutrient combinations for blood sugar control in diabetics. Since carbohydrates have the most direct effect on glucose levels, the majority have looked at replacing carbohydrates with fat or protein. In general, these studies have not found that carb replacement improves long-term control. [1,2,3,4,5,6,7,8,9,15]
- Diabetics should focus on overall calorie intake and weight control. For patients who consume a lot of carbohydrates in the form of sugars and/or starches, reducing these foods may help lower blood sugars.
- CARBOHYDRATES
- Overview
- Carbohydrates have the most direct effect on glucose levels, making them the focus of many diabetic recommendations. Guidance from the ADA on carbohydrate intake is provided below, along with their statement on the glycemic index, a measure of how much blood sugar levels tend to rise after the ingestion of various carbohydrate-containing foods.
- ADA recommendations for carbohydrates
- Carbohydrates should ideally be consumed from fruits, vegetables, whole grains, beans, nuts, and dairy products (low-fat milk and yogurt)
- Patients who use flexible insulin dosing (prandial) should learn carbohydrate counting and how to adjust insulin appropriately based on carbohydrate consumption (see insulin dosing). In some cases, education on considering fat and protein content to determine mealtime insulin dosing is recommended to improve glycemic control.
- For patients who use daily fixed insulin dosing, a consistent pattern of carbohydrate intake with respect to time and amount may be recommended to improve glycemic control and reduce the risk of hypoglycemia
- Sugar-sweetened beverages should be avoided
- Foods with added sugar should be minimized
- Individuals who consume meals containing more protein and fat than usual may also need to make mealtime insulin dose adjustments to compensate for delayed postprandial hyperglycemia [17,18]
- ADA statement on the glycemic index
- The literature concerning glycemic index and glycemic load in individuals with diabetes is complex often yielding mixed results
- In some studies, lowering dietary glycemic load has demonstrated A1C reductions of 0.2% to 0.5%
- Studies longer than 12 weeks have found no significant effect of glycemic index or glycemic load on A1C levels independent of weight loss [17]
- PROTEIN
- Overview
- Dietary protein can affect kidney function in people with kidney disease (see diabetic kidney disease). Recommendations from the ADA on dietary protein are given below.
- ADA recommendations in diabetics with normal kidney function
- The ADA recommends diabetics with normal kidney function consume 15 - 20% of total calories from protein or 1.5 g/kg body weight/day
- In individuals with type 2 diabetes, protein intake may enhance or increase the insulin response to dietary carbohydrates. Therefore, carbohydrate sources high in protein should not be used to treat or prevent hypoglycemia due to the potential concurrent rise in endogenous insulin.
- ADA recommendations in diabetics with albuminuria and/or reduced glomerular filtration rate,
- Dietary protein should be maintained at 0.8 g/kg body weight/day
- FATS AND CHOLESTEROL
- Overview
- See fatty acids, dietary cholesterol, and fish oil for information on dietary fat sources
- ADA recommendations
- Data on the ideal total dietary fat content for people with diabetes are inconclusive
- Total fat consumption should be 20 - 35% of total calories with saturated fats being < 10% of total calories
- Trans fatty acids should be as low as possible
- Dietary cholesterol consumption should be < 200 mg/day
- A Mediterranean-style diet rich in monounsaturated and polyunsaturated fats may be considered to improve glucose metabolism and lower CVD risk and can be an effective alternative to a diet low in total fat but relatively high in carbohydrates
- Foods rich in long-chain n-3 fatty acids such as fatty fish (EPA and DHA) and nuts and seeds (ALA) are recommended to prevent or treat CVD
- Evidence does not support n-3 fatty acid (fish oil) supplementation [17]
- MICRONUTRIENTS
- Overview
- Micronutrients are vitamins and minerals (e.g. zinc, magnesium, vitamin A) necessary for numerous metabolic processes. In the U.S., micronutrient deficiencies are rare, and most people consume supplements because they believe they provide some unproven health benefits.
- ADA recommendations
- There is no clear evidence that dietary supplementation with vitamins, minerals, herbs, or spices can improve outcomes in people with diabetes who do not have underlying deficiencies, and are not generally recommended. There may be safety concerns regarding the long-term use of antioxidant supplements such as vitamins E and C and carotene.
- SODIUM
- Overview
- Higher sodium intake has been linked to higher blood pressure, and theoretically, this raises the risk of cardiovascular disease. In trials, the association between salt intake and heart disease has been mixed, with most studies finding a "U-shaped" relationship. In larger studies, sodium intake of 4000 - 6000 mg a day conferred the lowest risk, while levels below and above this range had higher risk. Most professional organizations, like the ADA (see below), recommend intake of less than 2300 mg a day, a level well below the range supported by evidence (see sodium and hypertension for more). In developed nations, the average sodium intake is 3600 - 4800 mg a day.
- ADA recommendations
- The ADA recommends that diabetics limit sodium consumption to less than 2300 mg/day [17]
- ALCOHOL
- Alcohol serving sizes
- A serving of alcohol is defined as the following:
- 12 oz of regular beer (not malt liquor)
- 5 oz of wine
- 1.5 oz of 80 proof liquor
- Calories from alcohol
- Alcohol itself has 7 calories/gram, but it does not directly affect blood sugars. Other contents of alcoholic beverages (e.g. carbs in beer, juices in mixed drinks) can raise glucose levels.
- ADA recommendations
- Limit drinks to one a day for women and two a day for men
- Diabetics on insulin or drugs that stimulate insulin secretion (ex. sulfonylureas) should consume alcohol with food to prevent late night hypoglycemia (low blood sugar)
- The alcohol itself does not affect blood sugar levels, but carbohydrates in alcoholic beverages can affect blood sugar levels [1]
- BALANCED DIET
- Overview
- Below is an outline of what the USDA considers a "balanced diet." In practice, few people consume a balanced diet on a daily basis. When a balanced diet is not possible, diabetics, at the very least, should still maintain a close watch over calorie intake.
- See the ADA Food Advisor for more information
- USDA recommendations for a balanced diet
- The USDA divides foods into 7 groups and makes recommendations based on these categories
- See the USDA website for help with creating a balanced diet
| Food Group | Amount per day | Examples |
|---|---|---|
| Fruit group | 2 cups | apple, orange, etc. |
| Vegetable group | 2.5 cups | raw vegetables, vegetable juice, etc. |
| Grain group | 6 oz (1/2 as whole grain) | bread, rice, pasta, cereal |
| Meats and beans | 5 and 1/2 oz | lean chicken, lean beef, eggs, fish, beans |
| Milk group | 3 cups | milk, yogurt, low fat cheese |
| Oils | 6 teaspoons | vegetable oils, light salad dressing |
| Discretionary calories | 267 calories | table sugar, jelly, sweets |
- ADA recommendations
- The DASH diet and the Mediterranean diet are both considered healthy diets by the ADA. Links to information about each diet and the ADA nutrition website are provided below.
- BIBLIOGRAPHY
- 1 - PMID 18165339
- 2 - PMID 17636747
- 3 - PMID 15331548
- 4 - PMID 19366978
- 5 - PMID 17684222
- 6 - PMID 19106241
- 7 - PMID 19407076
- 8 - PMID 20150293
- 9 - PMID 21246185
- 10 - PMID 10805824
- 11 - PMID 14963049
- 12 - PMID 17031010
- 13 - PMID 19090602
- 14 - PMID 20959501
- 15 - PMID 18957534
- 16 - PMID 15333500
- 17 - PMID 29222370 ADA Standards of Medical Care in Diabetes 2018, Diabetes Care (2018)
- 18 - ADA Standards of Medical Care in Diabetes (2019)