Table 7—

Major nutrition recommendations

Nutrition RecommendationsGrading
Carbohydrate
• Foods containing carbohydrate from whole grains, fruits, vegetables, and low-fat milk are important components and should be included in a healthy diet.A
• With regard to the glycemic effects of carbohydrates, the total amount of carbohydrate in meals or snacks is more important than the source or type.A
• Because sucrose does not increase glycemia to a greater extent than isocaloric amounts of starch, sucrose and sucrose-containing foods do not need to be restricted by people with diabetes, however, they should be substituted for other carbohydrate sources or, if added, be covered with insulin or other glucose-lowering medication.A
• Nonnutritive sweeteners are safe when consumed within the ADI levels established by the FDA.A
• Individuals receiving intensive insulin therapy should adjust their premeal insulin dosages based on the carbohydrate content of meals.B
• Although the use of low–glycemic index foods may reduce postprandial hyperglycemic, there is not sufficient evidence of long-term benefit to recommend use of low-glycemic index diets as a primary strategy in food/meal planning.B
• As far the general public, consumption of dietary fiber is to be encouraged; however, there is no reason to recommend that people with diabetes consume a greater amount of fiber than other Americans.B
• Individuals receiving fixed daily insulin dosages should try to be consistent in day-to-day carbohydrate intake.C
• Carbohydrate and monounsaturated fat should together provide 60–70% of energy intake. However, the individual’s metabolic profile and need for weight loss should be considered when determining the monounsaturated fat content of the diet.E
• Sucrose and sucrose-containing foods should be eaten in the context of a healthy diet.E
Protein
• In individuals with controlled type 2 diabetes, ingested protein does not increase plasma glucose concentrations, although ingested protein is just as potent a stimulant of insulin secretion as carbohydrate.B
• For persons with diabetes, especially those not with less-than-optimal glucose control, the protein requirements may be greater than the RDA, but not greater than usual intake.B
• For individuals with diabetes, there is no evidence to suggest that usual protein intake (15–20% of total daily energy) should be modified if renal function is normal.E
• The long-term effects of diets high in protein and low in carbohydrate are unknown. Although such diets may produce short-term weight loss and improved glycemia, it has not been established that weight loss is maintained long-term. The long-term effect of such diets on LDL cholesterol is also a concern.E
Fat
• In all, <10% of energy intake should be derived from saturated fats. Some individuals (i.e., those with LDL cholesterol ≥100 mg/dl) may benefit from lowering saturated fat intake to <70% of energy intake.A
• Dietary cholesterol intake should be <300 mg/day. Some individuals (i.e., those with LDL cholesterol ≥100 mg/dl) may benefit from lowering dietary cholesterol to <200 mg per day.A
• To lower LDL cholesterol, energy derived from saturated fat can be reduced if weight loss is desirable or replaced with either carbohydrate or monounsaturated fat if weight loss is not a goal.B
• Intake of transunsaturated fatty acids should be minimized.B
• Reduced-fat diets when maintained long term contribute to modest loss of weight and improvement in dyslipidemia.B
• Polyunsaturated fat intake should be ∼10% of energy intake.C
Energy balance and obesity
• In insulin-resistant individuals, reduced energy intake and modest weight loss improve insulin resistance and glycemia in the short-term.A
• Structured programs that emphasize lifestyle changes including education, reduced fat (<30% of daily energy) and energy intake, regular physical activity, and regular participant contact, can produce long-term weight loss on the order of 5 to 7% of starting weight.A
• Exercise and behavior modification are most useful as adjuncts to other weight-loss strategies. Exercise is helpful in maintenance of weight loss.A
• Standard weight-reduction diets, when used alone, are unlikely to produce long-term weight loss. Structured, intensive lifestyle programs are necessary.A
Micronutrients
• There is no clear evidence of benefit from vitamin or mineral supplementation in people with diabetes who do not have underlying deficiencies. Exceptions include folate for prevention of birth defects and calcium for prevention of bone disease.B
• Routine supplementation of the diet with antioxidants is not advised because of uncertainties related to long-term efficacy and safety.B
Nutrition RecommendationsGrading
Alcohol
• If individuals choose to drink alcohol, daily intake should be limited to one drink for adult women and two drinks for adult men. One drink is defined as a 12-oz beer, a 5-oz glass of wine, or 1.5-oz glass of distilled spirits.B
• To reduce risk of hypoglycemia, alcohol should be consumed with food.B
Children and adolescents with diabetes
• Individualized food/meal plans and intensive insulin regimens can provide flexibility for children and adolescents with diabetes to accommodate irregular meal times and schedules, varying appetite, and varying activity levels.E
• Nutrient requirements for children and adolescents with type 1 or type 2 diabetes appear to be similar to requirements for same age nondiabetic children and adolescents.E
Pregnancy and lactation
• Nutrition requirements during pregnancy and lactation are similar for women with and without diabetes.E
• Medical nutrition therapy for gestational diabetes focuses on food choices for appropriate weight gain, normoglycemia, and absence of ketones.E
• For some women with gestational diabetes, modest energy and carbohydrate restriction may be appropriate.E
Older adults
• Energy requirements for older adults are less than for younger adults.A
• Physical activity should be encouragedA
• In the elderly, undernutrition is more likely than overnutrition and therefore caution should be exercised when prescribing weight-loss diets.E
Acute complications
• Glucose is the preferred treatment for hypoglycemia, although any form of carbohydrate that contains glucose may be used.A
• Ingestion of 15–20 g of glucose is an effective treatment for hypoglycemia, but blood glucose may be only temporarily corrected.B
• During acute illnesses, testing blood glucose and blood or urine for ketones, drinking adequate amounts of fluids, and ingesting carbohydrate are important.B
• Initial response to treatment for hypoglycemia should be seen in ∼10–20 min; however, blood glucose should be evaluated in ∼60 min, as additional treatment may be necessary.E
Hypertension
• In both normotensive and hypertensive individuals, a reduction in sodium intake lowers blood pressure.A
• A modest amount of weight loss beneficially affects blood pressure.A
•  The goal should be to reduce sodium intake 2,400 mg (100 mmol) or sodium chloride to 6,000 mg per day.E
Dyslipidemia
• For persons with elevated LDL cholesterol, saturated fatty acids and transsaturated fatty acids should be limited to <10% and perhaps to <7% of energy.B
• Energy derived from saturated fat can be reduced if weight loss is desirable or replaced with either carbohydrates or monounsaturated fats if weight loss is not a goal.E
• For individuals with elevated plasma triglycerides, reduced HDL cholesterol, and small dense LDL cholesterol (the metabolic syndrome), improved glycemic control, modest weight loss, dietary saturated fat restriction, increased physical activity, and incorporation of monounsaturated fats may be beneficial.B
Nephropathy
• In individuals with microalbuminuria, reduction of protein to 0.8–1.0 g · kg1 · body weight per day and in individuals with overt nephropathy, reduction to 0.8 g · kg1 · body wt per day, may slow the progression of nephropathy.C
Catabolic illness
• The energy needs of most hospitalized patients can be met by providing 25–35 kcal/kg body wt.E
• Protein needs are between 1.0 and 1.5 g/kg body wt, with the higher end of the range being for more stressed patients.E
Prevention of diabetes
• Structured programs that emphasize lifestyle changes including education, reduced fat and energy intake, regular physical activity, and regular participant contact can produce long-term weight loss of 5–7% of starting weight and reduce the risk for developing diabetes.A
• All individuals, especially family members of individuals with type 2 diabetes, should be encouraged to engage in regular physical activity to decrease risk of developing type 2 diabetes.B
  • Scientific principles ranked based on the American Diabetes Association grading system. The highest ranking, A, is assigned when there is supportive evidence from multiple, well-conducted studies; B is an intermediate rating; C is a lower ranking; and E represents recommendations based on expert consensus.