- 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
- Caloric requirements
- 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 that will lead to weight loss
- 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]
- The links below provide information on determining ideal body weight, caloric requirements, and tips on dieting:
- 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
- Macronutrients
- Macronutrients are the nutrients in food that supply calories
- Macronutrients include:
- USDA recommendations
| USDA recommended macronutrient distribution for the general public | |
|---|---|
| Macronutrient | % of total calories |
| Carbohydrates | 45 - 65% |
| Fats | 20 - 35% |
| Protein | 10 - 35% |
- Macronutrient distribution in diabetes
- A number of studies have looked at various macronutrient combinations to help control blood sugars in diabetics
- Carbohydrates have the most direct effect on blood sugar levels; therefore, most studies have looked at replacing carbohydrates with fat or protein
- We reviewed a number of randomized controlled trials, cohort studies, and meta-analyses
- In general, these studies did not find any conclusive evidence that varying the macronutrient mix in diabetic diets has a long-term effect on blood sugar control [1,2,3,4,5,6,7,8,9,15]
- Professional guidelines:
- 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
- StraightHealthcare analysis:
- There is no evidence that altering the recommended macronutrient proportions improves blood sugar control in diabetes
- Diabetics should focus on controlling 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.
- The ADA recommends that macronutrient distribution be tailored around individual eating habits
- CARBOHYDRATES
- Overview
- Carbohydrates have the most direct effect on blood sugar levels, and therefore they are the focus of a number of diabetic recommendations
- The glycemic index is a value given to foods that reflects their effect on glucose levels when consumed
- ADA recommendations for carbohydrates and the glycemic index are given below
- The ADA makes the following general recommendations for carbohydrate consumption in diabetics:
- 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]
- The ADA makes the following statements about 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 for more.
- The ADA makes two separate recommendations for protein intake in diabetics
- ADA dietary protein 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 dietary protein 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 dietary fat 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 include vitamins and minerals (ex. magnesium, vitamin A, etc.) that are necessary for various metabolic processes
- In diabetics who consume a balanced diet, micronutrient deficiency is rare
- ADA micronutrient 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
- Reducing sodium intake may help lower blood pressure in some people
- When it comes to clinical outcomes, a number of large observational studies have now found that sodium intake has a "U-shaped" relationship with cardiovascular outcomes with both lower and higher sodium intakes being associated with worse outcomes. In some of the larger studies, sodium intake of 4000 - 6000 mg a day conferred the lowest risk for cardiovascular outcomes. This level is well above the recommended intake from a number of professional organizations. In developed nations, the average sodium consumption is 3600 - 4800 mg a day.
- See sodium and hypertension for more
- ADA sodium recommendations:
- The ADA recommends that diabetics limit sodium consumption to < 2300 mg/day [17]
- ALCOHOL AND DIABETES
- 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 provides 7 calories/gram, but has no direct effect on blood sugar levels
- Other contents of alcoholic beverages will add to the overall calories and can affect blood sugar levels (ex. carbs in beer and soda and juices in mixed drinks)
- The ADA makes the following recommendations regarding alcohol consumption in diabetics:
- 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
- Individual diets vary widely from person-to-person and from day-to-day
- 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, at the very least, diabetics should still maintain a close watch over caloric intake
- The ADA has a website that can help to guide food choices - ADA Food Advisor
- USDA recommendations for a balanced diet
- The USDA divides foods into 7 groups
- Diabetics can use these recommendations as a guide to help achieve a balanced diet
- The USDA also has a website that discusses healthy eating - USDA website
| 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 ADA references three diet plans as "examples of healthful eating" for diabetics. Links to information about each plan are given below.
- BIBLIOGRAPHY
- What is PMID?
- PI = Manufacturer's Package Insert
- # PMID
- 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)