Nutrition Therapy Recommendations for the Management of Adults With Diabetes

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Add to Selected Citations. Introduction to Health Care 3 ed. In , the Institute of Medicine IOM released a report concluding that evidence demonstrates that medical nutrition therapy MNT can improve clinical outcomes while possibly decreasing the cost to Medicare of managing diabetes Alcohol consumption may place people with diabetes at increased risk for delayed hypoglycemia, especially if taking insulin or insulin secretagogues. Nutrition portal Food portal. Palatability, limited food choices, and gastrointestinal side effects are potential barriers to achieving such high-fiber intakes.

3 in 5 babies not breastfed in the first hour of life

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Trans fats are a type of unsaturated fat with trans -isomer bonds; these are rare in nature and in foods from natural sources; they are typically created in an industrial process called partial hydrogenation.

There are nine kilocalories in each gram of fat. Fatty acids such as conjugated linoleic acid , catalpic acid, eleostearic acid and punicic acid , in addition to providing energy, represent potent immune modulatory molecules.

Saturated fats typically from animal sources have been a staple in many world cultures for millennia. Saturated and some trans fats are typically solid at room temperature such as butter or lard , while unsaturated fats are typically liquids such as olive oil or flaxseed oil.

Trans fats are very rare in nature, and have been shown to be highly detrimental to human health, but have properties useful in the food processing industry, such as rancidity resistance. Most fatty acids are non-essential, meaning the body can produce them as needed, generally from other fatty acids and always by expending energy to do so. However, in humans, at least two fatty acids are essential and must be included in the diet.

An appropriate balance of essential fatty acids— omega-3 and omega-6 fatty acids —seems also important for health, although definitive experimental demonstration has been elusive. Both of these "omega" long-chain polyunsaturated fatty acids are substrates for a class of eicosanoids known as prostaglandins , which have roles throughout the human body. They are hormones , in some respects. The omega-3 eicosapentaenoic acid EPA , which can be made in the human body from the omega-3 essential fatty acid alpha-linolenic acid ALA , or taken in through marine food sources, serves as a building block for series 3 prostaglandins e.

The omega-6 dihomo-gamma-linolenic acid DGLA serves as a building block for series 1 prostaglandins e. An appropriately balanced intake of omega-3 and omega-6 partly determines the relative production of different prostaglandins, which is one reason why a balance between omega-3 and omega-6 is believed important for cardiovascular health.

In industrialized societies, people typically consume large amounts of processed vegetable oils, which have reduced amounts of the essential fatty acids along with too much of omega-6 fatty acids relative to omega-3 fatty acids.

Moreover, the conversion desaturation of DGLA to AA is controlled by the enzyme deltadesaturase , which in turn is controlled by hormones such as insulin up-regulation and glucagon down-regulation.

The amount and type of carbohydrates consumed, along with some types of amino acid, can influence processes involving insulin, glucagon, and other hormones; therefore, the ratio of omega-3 versus omega-6 has wide effects on general health, and specific effects on immune function and inflammation , and mitosis i.

Proteins are structural materials in much of the animal body e. They also form the enzymes that control chemical reactions throughout the body. Each protein molecule is composed of amino acids , which are characterized by inclusion of nitrogen and sometimes sulphur these components are responsible for the distinctive smell of burning protein, such as the keratin in hair.

The body requires amino acids to produce new proteins protein retention and to replace damaged proteins maintenance. As there is no protein or amino acid storage provision, amino acids must be present in the diet. Excess amino acids are discarded, typically in the urine. For all animals, some amino acids are essential an animal cannot produce them internally and some are non-essential the animal can produce them from other nitrogen-containing compounds.

About twenty amino acids are found in the human body, and about ten of these are essential and, therefore, must be included in the diet. A diet that contains adequate amounts of amino acids especially those that are essential is particularly important in some situations: A complete protein source contains all the essential amino acids; an incomplete protein source lacks one or more of the essential amino acids. It is possible with protein combinations of two incomplete protein sources e.

However, complementary sources of protein do not need to be eaten at the same meal to be used together by the body. Water is excreted from the body in multiple forms; including urine and feces , sweating , and by water vapour in the exhaled breath. Therefore, it is necessary to adequately rehydrate to replace lost fluids. Early recommendations for the quantity of water required for maintenance of good health suggested that 6—8 glasses of water daily is the minimum to maintain proper hydration.

Most of this quantity is contained in prepared foods. For healthful hydration, the current EFSA guidelines recommend total water intakes of 2. These reference values include water from drinking water, other beverages, and from food. The EFSA panel also determined intakes for different populations. Recommended intake volumes in the elderly are the same as for adults as despite lower energy consumption, the water requirement of this group is increased due to a reduction in renal concentrating capacity.

Dehydration and over-hydration - too little and too much water, respectively - can have harmful consequences. Drinking too much water is one of the possible causes of hyponatremia , i.

Pure ethanol provides 7 calories per gram. For distilled spirits , a standard serving in the United States is 1. A 5 ounce serving of wine contains to calories. A 12 ounce serving of beer contains 95 to calories. Alcoholic beverages are considered empty calorie foods because other than calories, these contribute no essential nutrients. The micronutrients are minerals , vitamins , and others.

Dietary minerals are inorganic chemical elements required by living organisms, [70] other than the four elements carbon , hydrogen , nitrogen , and oxygen that are present in nearly all organic molecules.

The term "mineral" is archaic, since the intent is to describe simply the less common elements in the diet. Some are heavier than the four just mentioned, including several metals , which often occur as ions in the body. Some dietitians recommend that these be supplied from foods in which they occur naturally, or at least as complex compounds, or sometimes even from natural inorganic sources such as calcium carbonate from ground oyster shells.

Some minerals are absorbed much more readily in the ionic forms found in such sources. On the other hand, minerals are often artificially added to the diet as supplements; the most famous is likely iodine in iodized salt which prevents goiter. Many elements are essential in relative quantity; they are usually called "bulk minerals". Some are structural, but many play a role as electrolytes.

Many elements are required in trace amounts, usually because they play a catalytic role in enzymes. Vitamins are essential nutrients, [70] necessary in the diet for good health. Vitamin D is an exception, as it can be synthesized in the skin in the presence of UVB radiation , and many animal species can synthesize vitamin C. Vitamin deficiencies may result in disease conditions, including goitre , scurvy , osteoporosis , impaired immune system, disorders of cell metabolism, certain forms of cancer, symptoms of premature aging, and poor psychological health , among many others.

Phytochemicals such as polyphenols are compounds produced naturally in plants phyto means "plant" in Greek. In general, the term is used to refer to compounds which do not appear to be nutritionally essential and yet may have positive impacts on health.

To date, there is no conclusive evidence in humans that polyphenols or other non-nutrient compounds from plants have health benefit effects. While initial studies sought to reveal if nutrient antioxidant supplements might promote health, one meta-analysis concluded that supplementation with vitamins A and E and beta-carotene did not convey any benefits and may in fact increase risk of death.

Vitamin C and selenium supplements did not impact mortality rate. Health effects of non-nutrient phytochemicals such as polyphenols were not assessed in this review.

Animal intestines contain a large population of gut flora. In humans, the four dominant phyla are Firmicutes , Bacteroidetes , Actinobacteria , and Proteobacteria. Bacteria in the large intestine perform many important functions for humans, including breaking down and aiding in the absorption of fermentable fiber, stimulating cell growth, repressing the growth of harmful bacteria, training the immune system to respond only to pathogens, producing vitamin B 12 , and defending against some infectious diseases.

There is not yet a scientific consensus as to health benefits accruing from probiotics or prebiotics. Carnivore and herbivore diets are contrasting, with basic nitrogen and carbon proportions vary for their particular foods. Many herbivores rely on bacterial fermentation to create digestible nutrients from indigestible plant cellulose, while obligate carnivores must eat animal meats to obtain certain vitamins or nutrients their bodies cannot otherwise synthesize.

Plant nutrition is the study of the chemical elements that are necessary for plant growth. Some elements are directly involved in plant metabolism. However, this principle does not account for the so-called beneficial elements, whose presence, while not required, has clear positive effects on plant growth. A nutrient that is able to limit plant growth according to Liebig's law of the minimum is considered an essential plant nutrient if the plant cannot complete its full life cycle without it.

There are 16 essential plant soil nutrients, besides the three major elemental nutrients carbon and oxygen that are obtained by photosynthetic plants from carbon dioxide in air, and hydrogen , which is obtained from water. Plants uptake essential elements from the soil through their roots and from the air consisting of mainly nitrogen and oxygen through their leaves. Green plants obtain their carbohydrate supply from the carbon dioxide in the air by the process of photosynthesis.

Carbon and oxygen are absorbed from the air, while other nutrients are absorbed from the soil. These hydrogen ions displace cations attached to negatively charged soil particles so that the cations are available for uptake by the root.

In the leaves, stomata open to take in carbon dioxide and expel oxygen. The carbon dioxide molecules are used as the carbon source in photosynthesis. Although nitrogen is plentiful in the Earth's atmosphere, very few plants can use this directly. Most plants, therefore, require nitrogen compounds to be present in the soil in which they grow. This is made possible by the fact that largely inert atmospheric nitrogen is changed in a nitrogen fixation process to biologically usable forms in the soil by bacteria.

Plant nutrition is a difficult subject to understand completely, partially because of the variation between different plants and even between different species or individuals of a given clone. Elements present at low levels may cause deficiency symptoms, and toxicity is possible at levels that are too high. Furthermore, deficiency of one element may present as symptoms of toxicity from another element, and vice versa.

Canada's Food Guide is an example of a government-run nutrition program. Produced by Health Canada , the guide advises food quantities, provides education on balanced nutrition, and promotes physical activity in accordance with government-mandated nutrient needs.

Like other nutrition programs around the world, Canada's Food Guide divides nutrition into four main food groups: Dietary and physical activity guidelines from the USDA are presented in the concept of MyPlate , which superseded the food pyramid , which replaced the Four Food Groups. Department of Health and Human Services provides a sample week-long menu that fulfills the nutritional recommendations of the government. Governmental organisations have been working on nutrition literacy interventions in non-primary health care settings to address the nutrition information problem in the U.

The FNP has developed a series of tools to help families participating in the Food Stamp Program stretch their food dollar and form healthful eating habits including nutrition education. It is designed to assist limited-resource audiences in acquiring the knowledge, skills, attitudes, and changed behavior necessary for nutritionally sound diets, and to contribute to their personal development and the improvement of the total family diet and nutritional well-being.

Launched in , this program promotes lifelong healthful eating patterns and physically active lifestyles for children and their families. It is an interactive educational program designed to help prevent childhood obesity through classroom activities that teach children healthful eating habits and physical exercise.

Nutrition is taught in schools in many countries. In England and Wales , the Personal and Social Education and Food Technology curricula include nutrition, stressing the importance of a balanced diet and teaching how to read nutrition labels on packaging. In many schools, a Nutrition class will fall within the Family and Consumer Science or Health departments. In some American schools, students are required to take a certain number of FCS or Health related classes.

Nutrition is offered at many schools, and, if it is not a class of its own, nutrition is included in other FCS or Health classes such as: In many Nutrition classes, students learn about the food groups, the food pyramid, Daily Recommended Allowances, calories, vitamins, minerals, malnutrition, physical activity, healthful food choices, portion sizes, and how to live a healthy life. In the US, Registered dietitian nutritionists RDs or RDNs [89] are health professionals qualified to provide safe, evidence-based dietary advice which includes a review of what is eaten, a thorough review of nutritional health, and a personalized nutritional treatment plan.

They also provide preventive and therapeutic programs at work places, schools and similar institutions. Certified Clinical Nutritionists or CCNs, are trained health professionals who also offer dietary advice on the role of nutrition in chronic disease, including possible prevention or remediation by addressing nutritional deficiencies before resorting to drugs.

These Board Certified Nutritionists typically specialize in obesity and chronic disease. In order to become board certified, potential CNS candidate must pass an examination, much like Registered Dieticians. This exam covers specific domains within the health sphere including; Clinical Intervention and Human Health. The study found that health literacy increases with education and people living below the level of poverty have lower health literacy than those above it.

Another study examining the health and nutrition literacy status of residents of the lower Mississippi Delta found that 52 percent of participants had a high likelihood of limited literacy skills. For example, only 12 percent of study participants identified the My Pyramid graphic two years after it had been launched by the USDA. The study also found significant relationships between nutrition literacy and income level and nutrition literacy and educational attainment [93] further delineating priorities for the region.

Among these problems are the lack of information about food choices, a lack of understanding of nutritional information and its application to individual circumstances, limited or difficult access to healthful foods, and a range of cultural influences and socioeconomic constraints such as low levels of education and high levels of poverty that decrease opportunities for healthful eating and living.

The links between low health literacy and poor health outcomes has been widely documented [94] and there is evidence that some interventions to improve health literacy have produced successful results in the primary care setting.

More must be done to further our understanding of nutrition literacy specific interventions in non-primary care settings [93] in order to achieve better health outcomes. Malnutrition refers to insufficient, excessive, or imbalanced consumption of nutrients by an organism. In developed countries, the diseases of malnutrition are most often associated with nutritional imbalances or excessive consumption.

In developing countries, malnutrition is more likely to be caused by poor access to a range of nutritious foods or inadequate knowledge. The aim was to boost nutrition and livelihoods by producing a product that women could make and sell, and which would be accepted by the local community because of its local heritage.

Although under- and over-nutrition are often viewed as human problems, pet animals can be under- or overfed by their owners, domesticated animals can be undernourished for macro- and micro-nutrients, affecting growth and health, and wild animals can be undernourished to the point of starvation and death.

Nutritionism is the view that excessive reliance on food science and the study of nutrition can lead to poor nutrition and to ill health. It was originally credited to Gyorgy Scrinis , [96] and was popularized by Michael Pollan. Since nutrients are invisible, policy makers rely on nutrition experts to advise on food choices. Because science has an incomplete understanding of how food affects the human body, Pollan argues, nutritionism can be blamed for many of the health problems relating to diet in the Western World today.

ULs are set a safe fraction below amounts shown to cause health problems. ULs are part of Dietary Reference Intakes. When too much of one or more nutrients is present in the diet to the exclusion of the proper amount of other nutrients, the diet is said to be unbalanced. High calorie food ingredients such as vegetable oils, sugar and alcohol are referred to as "empty calories" because they displace from the diet foods that also contain protein, vitamins, minerals and fiber.

Research indicates that improving the awareness of nutritious meal choices and establishing long-term habits of healthy eating have a positive effect on cognitive and spatial memory capacity, with potential to increase a student's ability to process and retain academic information.

Some organizations have begun working with teachers, policymakers, and managed foodservice contractors to mandate improved nutritional content and increased nutritional resources in school cafeterias from primary to university level institutions.

Health and nutrition have been proven to have close links with overall educational success. There is limited research available that directly links a student's Grade Point Average G. Additional substantive data is needed to prove that overall intellectual health is closely linked to a person's diet, rather than just another correlation fallacy. Nutritional supplement treatment may be appropriate for major depression , bipolar disorder , schizophrenia , and obsessive compulsive disorder , the four most common mental disorders in developed countries.

Cancer is now common in developing countries. According to a study by the International Agency for Research on Cancer , "In the developing world, cancers of the liver, stomach and esophagus were more common, often linked to consumption of carcinogenic preserved foods, such as smoked or salted food, and parasitic infections that attack organs.

Several lines of evidence indicate lifestyle-induced hyperinsulinemia and reduced insulin function i. For example, hyperinsulinemia and insulin resistance are strongly linked to chronic inflammation, which in turn is strongly linked to a variety of adverse developments such as arterial microtrauma and clot formation i.

Hyperinsulinemia and insulin resistance the so-called metabolic syndrome are characterized by a combination of abdominal obesity , elevated blood sugar , elevated blood pressure , elevated blood triglycerides , and reduced HDL cholesterol. The state of obesity clearly contributes to insulin resistance, which in turn can cause type 2 diabetes. Virtually all obese and most type 2 diabetic individuals have marked insulin resistance. Although the association between overweight and insulin resistance is clear, the exact likely multifarious causes of insulin resistance remain less clear.

It has been demonstrated that appropriate exercise, more regular food intake, and reducing glycemic load see below all can reverse insulin resistance in overweight individuals and thereby lower their blood sugar level , in those with type 2 diabetes.

In addition, reduced leptin signaling to the brain may reduce leptin's normal effect to maintain an appropriately high metabolic rate. In any case, analogous to the way modern man-made pollution may possess the potential to overwhelm the environment's ability to maintain homeostasis , the recent explosive introduction of high glycemic index and processed foods into the human diet may possess the potential to overwhelm the body's ability to maintain homeostasis and health as evidenced by the metabolic syndrome epidemic.

Antinutrients are natural or synthetic compounds that interfere with the absorption of nutrients. Nutrition studies focus on antinutrients commonly found in food sources and beverages. The relatively recent increased consumption of sugar has been linked to the rise of some afflictions such as diabetes, obesity, and more recently heart disease. Increased consumption of sugar has been tied to these three, among others.

In the same time span that obesity doubled, diabetes numbers quadrupled in America. Increased weight, especially in the form of belly fat, and high sugar intake are also high risk factors for heart disease. Elevated amounts of Low-density lipoprotein LDL cholesterol, is the primary factor in heart disease. In order to avoid all the dangers of sugar, moderate consumption is paramount.

Since the Industrial Revolution some two hundred years ago, the food processing industry has invented many technologies that both help keep foods fresh longer and alter the fresh state of food as they appear in nature.

Cooling is the primary technology used to maintain freshness, whereas many more technologies have been invented to allow foods to last longer without becoming spoiled. These latter technologies include pasteurisation , autoclavation , drying , salting , and separation of various components, all of which appearing to alter the original nutritional contents of food. Pasteurisation and autoclavation heating techniques have no doubt improved the safety of many common foods, preventing epidemics of bacterial infection.

But some of the new food processing technologies have downfalls as well. Modern separation techniques such as milling , centrifugation , and pressing have enabled concentration of particular components of food, yielding flour, oils, juices, and so on, and even separate fatty acids, amino acids, vitamins, and minerals.

Inevitably, such large-scale concentration changes the nutritional content of food, saving certain nutrients while removing others. Heating techniques may also reduce food's content of many heat-labile nutrients such as certain vitamins and phytochemicals, and possibly other yet-to-be-discovered substances.

In addition, processed foods often contain potentially harmful substances such as oxidized fats and trans fatty acids. A dramatic example of the effect of food processing on a population's health is the history of epidemics of beri-beri in people subsisting on polished rice. Removing the outer layer of rice by polishing it removes with it the essential vitamin thiamine , causing beri-beri.

Another example is the development of scurvy among infants in the late 19th century in the United States. It turned out that the vast majority of sufferers were being fed milk that had been heat-treated as suggested by Pasteur to control bacterial disease. Pasteurisation was effective against bacteria, but it destroyed the vitamin C. As mentioned, lifestyle- and obesity-related diseases are becoming increasingly prevalent all around the world. There is little doubt that the increasingly widespread application of some modern food processing technologies has contributed to this development.

The food processing industry is a major part of modern economy, and as such it is influential in political decisions e. In any known profit-driven economy, health considerations are hardly a priority; effective production of cheap foods with a long shelf-life is more the trend.

In general, whole, fresh foods have a relatively short shelf-life and are less profitable to produce and sell than are more processed foods. Thus, the consumer is left with the choice between more expensive, but nutritionally superior, whole, fresh foods, and cheap, usually nutritionally inferior, processed foods.

Because processed foods are often cheaper, more convenient in both purchasing, storage, and preparation , and more available, the consumption of nutritionally inferior foods has been increasing throughout the world along with many nutrition-related health complications.

From Wikipedia, the free encyclopedia. This article is about Nutrition in general. For Nutrition in humans, see Human nutrition. For Nutrition in animals, see Animal nutrition. For nutrition in plants, see Plant nutrition. For the medical journal, see Nutrition journal. Mineral nutrient and Composition of the human body. List of antioxidants in food. Animal nutrition and Human nutrition.

Nutrition portal Food portal. Food Balance Wheel Biology: Bioenergetics Digestion Enzyme Dangers of poor nutrition Deficiency Avitaminosis is a deficiency of vitamins. Boron deficiency medicine Chromium deficiency Iron deficiency medicine Iodine deficiency Magnesium deficiency medicine Diabetes Eating disorders Illnesses related to poor nutrition Malnutrition Obesity Childhood obesity Starvation Food: Dieting Eating Healthy eating pyramid Nutritional rating systems Lists: Diets list List of food additives List of illnesses related to poor nutrition List of life extension related topics List of publications in nutrition List of unrefined sweeteners List of antioxidants List of phytochemicals Nutrients: Dietitian Nutritionist Food Studies Tools: Human Nutrition and Food".

Retrieved 13 December Understanding Nutrition 13 ed. Deficiency, How Much, Benefits, and More. The New York Times. Archived from the original on The Profession of Dietetics. A History of Nutrition. The Riverside Press Houghton Mifflin. Although structured lifestyle programs have been effective when delivered in well-funded clinical trials, it is not clear how the results should be translated into clinical practice.

Organization, delivery, and funding of lifestyle interventions are all issues that must be addressed. Third-party payers may not provide adequate benefits for sufficient MNT frequency and time to achieve weight loss goals Exercise and physical activity, by themselves, have only a modest weight loss effect.

However, exercise and physical activity are to be encouraged because they improve insulin sensitivity independent of weight loss, acutely lower blood glucose, and are important in long-term maintenance of weight loss 1. Weight loss with behavioral therapy alone also has been modest, and behavioral approaches may be most useful as an adjunct to other weight loss strategies.

The optimal macronutrient distribution of weight loss diets has not been established. Although low-fat diets have traditionally been promoted for weight loss, two randomized controlled trials found that subjects on low-carbohydrate diets lost more weight at 6 months than subjects on low-fat diets 19 , Another study of overweight women randomized to one of four diets showed significantly more weight loss at 12 months with the Atkins low-carbohydrate diet than with higher-carbohydrate diets 20a.

However, at 1 year, the difference in weight loss between the low-carbohydrate and low-fat diets was not significant and weight loss was modest with both diets. Changes in serum triglyceride and HDL cholesterol were more favorable with the low-carbohydrate diets. In one study, those subjects with type 2 diabetes demonstrated a greater decrease in A1C with a low-carbohydrate diet than with a low-fat diet A recent meta-analysis showed that at 6 months, low-carbohydrate diets were associated with greater improvements in triglyceride and HDL cholesterol concentrations than low-fat diets; however, LDL cholesterol was significantly higher on the low-carbohydrate diets Further research is needed to determine the long-term efficacy and safety of low-carbohydrate diets Although brain fuel needs can be met on lower-carbohydrate diets, long-term metabolic effects of very-low-carbohydrate diets are unclear, and such diets eliminate many foods that are important sources of energy, fiber, vitamins, and minerals and are important in dietary palatability Meal replacements liquid or solid prepackaged provide a defined amount of energy, often as a formula product.

Use of meal replacements once or twice daily to replace a usual meal can result in significant weight loss. However, meal replacement therapy must be continued indefinitely if weight loss is to be maintained. When very-low-calorie diets are stopped and self-selected meals are reintroduced, weight regain is common. Thus, very-low-calorie diets appear to have limited utility in the treatment of type 2 diabetes and should only be considered in conjunction with a structured weight loss program.

All cardiovascular risk factors except hypercholesterolemia improved in the surgical patients. Individuals at high risk for type 2 diabetes should be encouraged to achieve the U. There is not sufficient, consistent information to conclude that low—glycemic 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. 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.

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

The importance of preventing type 2 diabetes is highlighted by the substantial worldwide increase in the prevalence of diabetes in recent years. Genetic susceptibility appears to play a powerful role in the occurrence of type 2 diabetes. However, given that population gene pools shift very slowly over time, the current epidemic of diabetes likely reflects changes in lifestyle leading to diabetes.

Lifestyle changes characterized by increased energy intake and decreased physical activity appear to have together promoted overweight and obesity, which are strong risk factors for diabetes.

Several studies have demonstrated the potential for moderate, sustained weight loss to substantially reduce the risk for type 2 diabetes, regardless of whether weight loss was achieved by lifestyle changes alone or with adjunctive therapies such as medication or bariatricsurgery see energy balance section 1.

Moreover, both moderate-intensity and vigorous exercise can improve insulin sensitivity, independent of weight loss, and reduce risk for type 2 diabetes 1. S 26 strongly support the potential for moderate weight loss to reduce the risk for type 2 diabetes. In addition to preventing diabetes, the DPP lifestyle intervention improved several CVD risk factors, including dsylipidemia, hypertension, and inflammatory markers 29 , The DPP analysis indicated that lifestyle intervention was cost-effective 31 , but other analyses suggest that the expected costs needed to be reduced Both the Finnish Diabetes Prevention study and the DPP focused on reduced intake of calories using reduced dietary fat as a dietary intervention.

Of note, reduced intake of fat, particularly saturated fat, may reduce risk for diabetes by producing an energy-independent improvement in insulin resistance 1 , 33 , 34 , as well as by promoting weight loss.

It is possible that reduction in other macronutrients e. Several studies have provided evidence for reduced risk of diabetes with increased intake of whole grains and dietary fiber 1 , 35 — Whole grain—containing foods have been associated with improved insulin sensitivity, independent of body weight, and dietary fiber has been associated with improved insulin sensitivity and improved ability to secrete insulin adequately to overcome insulin resistance There is debate as to the potential role of low—glycemic index and —glycemic load diets in prevention of type 2 diabetes.

Thus, there is not sufficient, consistent information to conclude that low—glycemic load diets reduce risk for diabetes. Prospective randomized clinical trials will be necessary to resolve this issue. A American Diabetes Association statement reviewed this issue in depth 40 , and issues related to the role of glycemic index and glycemic load in diabetes management are addressed in more detail in the carbohydrate section of this document.

Observational studies suggest a U- or J-shaped association between moderate consumption of alcohol one to three drinks [15—45 g alcohol] per day and decreased risk of type 2 diabetes 41 , 42 , coronary heart disease CHD 42 , 43 , and stroke However, heavy consumption of alcohol greater than three drinks per day , may be associated with increased incidence of diabetes If alcohol is consumed, recommendations from the USDA Dietary Guidelines for Americans suggest no more than one drink per day for women and two drinks per day for men Although selected micronutrients may affect glucose and insulin metabolism, to date, there are no convincing data that document their role in the development of diabetes.

No nutrition recommendations can be made for the prevention of type 1 diabetes at this time 1. Increasing overweight and obesity in youth appears to be related to the increased prevalence of type 2 diabetes, particularly in minority adolescents. Although there are insufficient data at present to warrant any specific recommendations for the prevention of type 2 diabetes in youth, interventions similar to those shown to be effective for prevention of type 2 diabetes in adults lifestyle changes including reduced energy intake and regular physical activity are likely to be beneficial.

Clinical trials of such interventions are ongoing in children. A dietary pattern that includes carbohydrate from fruits, vegetables, whole grains, legumes, and low-fat milk is encouraged for good health.

Monitoring carbohydrate, whether by carbohydrate counting, exchanges, or experienced-based estimation remains a key strategy in achieving glycemic control. The use of glycemic index and load may provide a modest additional benefit over that observed when total carbohydrate is considered alone.

Sucrose-containing foods can be substituted for other carbohydrates in the meal plan or, if added to the meal plan, covered with insulin or other glucose-lowering medications. Care should be taken to avoid excess energy intake. As for the general population, people with diabetes are encouraged to consume a variety of fiber-containing foods.

However, evidence is lacking to recommend a higher fiber intake for people with diabetes than for the population as a whole. Sugar alcohols and nonnutritive sweeteners are safe when consumed within the daily intake levels established by the Food and Drug Administration FDA. Control of blood glucose in an effort to achieve normal or near-normal levels is a primary goal of diabetes management.

Food and nutrition interventions that reduce postprandial blood glucose excursions are important in this regard, since dietary carbohydrate is the major determinant of postprandial glucose levels. Low-carbohydrate diets might seem to be a logical approach to lowering postprandial glucose.

However, foods that contain carbohydrate are important sources of energy, fiber, vitamins, and minerals and are important in dietary palatability.

Therefore, these foods are important components of the diet for individuals with diabetes. Issues related to carbohydrate and glycemia have previously been extensively reviewed in American Diabetes Association reports and nutrition recommendations for the general public 1 , 2 , 22 , 40 , Blood glucose concentration following a meal is primarily determined by the rate of appearance of glucose in the blood stream digestion and absorption and its clearance from the circulation Insulin secretory response normally maintains blood glucose in a narrow range, but in individuals with diabetes, defects in insulin action, insulin secretion, or both impair regulation of postprandial glucose in response to dietary carbohydrate.

Both the quantity and the type or source of carbohydrates found in foods influence postprandial glucose levels. A ADA statement addressed the effects of the amount and type of carbohydrate in diabetes management The 1-year follow-up data also indicate that the macronutrient composition of the treatment groups only differed with respect to carbohydrate intake mean intake of vs.

Thus, questions about the long-term effects on intake and metabolism, as well as safety, need further research. The amount of carbohydrate ingested is usually the primary determinant of postprandial response, but the type of carbohydrate also affects this response. Intrinsic variables that influence the effect of carbohydrate-containing foods on blood glucose response include the specific type of food ingested, type of starch amylose versus amylopectin , style of preparation cooking method and time, amount of heat or moisture used , ripeness, and degree of processing.

Extrinsic variables that may influence glucose response include fasting or preprandial blood glucose level, macronutrient distribution of the meal in which the food is consumed, available insulin, and degree of insulin resistance. The glycemic index of foods was developed to compare the postprandial responses to constant amounts of different carbohydrate-containing foods The glycemic index of a food is the increase above fasting in the blood glucose area over 2 h after ingestion of a constant amount of that food usually a g carbohydrate portion divided by the response to a reference food usually glucose or white bread.

The glycemic loads of foods, meals, and diets are calculated by multiplying the glycemic index of the constituent foods by the amounts of carbohydrate in each food and then totaling the values for all foods.

Foods with low glycemic indexes include oats, barley, bulgur, beans, lentils, legumes, pasta, pumpernickel coarse rye bread, apples, oranges, milk, yogurt, and ice cream. Fiber, fructose, lactose, and fat are dietary constituents that tend to lower glycemic response.

Potential methodological problems with the glycemic index have been noted Several randomized clinical trials have reported that low—glycemic index diets reduce glycemia in diabetic subjects, but other clinical trials have not confirmed this effect Moreover, the variability in responses to specific carbohydrate-containing food is a concern Nevertheless, a recent meta-analysis of low—glycemic index diet trials in diabetic subjects showed that such diets produced a 0.

However, it appears that most individuals already consume a moderate—glycemic index diet 39 , Thus, it appears that in individuals consuming a high—glycemic index diet, low—glycemic index diets can produce a modest benefit in controlling postprandial hyperglycemia.

In diabetes management, it is important to match doses of insulin and insulin secretagogues to the carbohydrate content of meals. A variety of methods can be used to estimate the nutrient content of meals, including carbohydrate counting, the exchange system, and experience-based estimation. By testing pre- and postprandial glucose, many individuals use experience to evaluate and achieve postprandial glucose goals with a variety of foods. To date, research has not demonstrated that one method of assessing the relationship between carbohydrate intake and blood glucose response is better than other methods.

Palatability, limited food choices, and gastrointestinal side effects are potential barriers to achieving such high-fiber intakes. Substantial evidence from clinical studies demonstrates that dietary sucrose does not increase glycemia more than isocaloric amounts of starch 1.

Thus, intake of sucrose and sucrose-containing foods by people with diabetes does not need to be restricted because of concern about aggravating hyperglycemia. Sucrose can be substituted for other carbohydrate sources in the meal plan or, if added to the meal plan, adequately covered with insulin or another glucose-lowering medication.

Additionally, intake of other nutrients ingested with sucrose, such as fat, need to be taken into account, and care should be taken to avoid excess energy intake. In individuals with diabetes, fructose produces a lower postprandial glucose response when it replaces sucrose or starch in the diet; however, this benefit is tempered by concern that fructose may adversely affect plasma lipids 1.

Therefore, the use of added fructose as a sweetening agent in the diabetic diet is not recommended. There is, however, no reason to recommend that people with diabetes avoid naturally occurring fructose in fruits, vegetables, and other foods.

Reduced calorie sweeteners approved by the FDA include sugar alcohols polyols such as erythritol, isomalt, lactitol, maltitol, mannitol, sorbitol, xylitol, tagatose, and hydrogenated starch hydrolysates. Studies of subjects with and without diabetes have shown that sugar alcohols produce a lower postprandial glucose response than sucrose or glucose and have lower available energy 1.

When calculating carbohydrate content of foods containing sugar alcohols, subtraction of half the sugar alcohol grams from total carbohydrate grams is appropriate.

Use of sugar alcohols as sweeteners reduces the risk of dental caries. However, there is no evidence that the amounts of sugar alcohols likely to be consumed will reduce glycemia, energy intake, or weight.

The use of sugar alcohols appears to be safe; however, they may cause diarrhea, especially in children. The FDA has approved five nonnutritive sweeteners for use in the U. These are acesulfame potassium, aspartame, neotame, saccharin, and sucralose.

Before being allowed on the market, all underwent rigorous scrutiny and were shown to be safe when consumed by the public, including people with diabetes and women during pregnancy. Clinical studies involving subjects without diabetes provide no indication that nonnutritive sweeteners in foods will cause weight loss or weight gain It has been proposed that foods containing resistant starch starch physically enclosed within intact cell structures as in some legumes, starch granules as in raw potato, and retrograde amylose from plants modified by plant breeding to increase amylose content or high-amylose foods, such as specially formulated cornstarch, may modify postprandial glycemic response, prevent hypoglycemia, and reduce hyperglycemia.

However, there are no published long-term studies in subjects with diabetes to prove benefit from the use of resistant starch. 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. The primary goal with respect to dietary fat in individuals with diabetes is to limit saturated fatty acids, trans fatty acids, and cholesterol intakes so as to reduce risk for CVD.

Saturated and trans fatty acids are the principal dietary determinants of plasma LDL cholesterol. In nondiabetic individuals, reducing saturated and trans fatty acids and cholesterol intakes decreases plasma total and LDL cholesterol.

Reducing saturated fatty acids may also reduce HDL cholesterol. Studies in individuals with diabetes demonstrating the effects of specific percentages of dietary saturated and trans fatty acids and specific amounts of dietary cholesterol on plasma lipids are not available. Therefore, because of a lack of specific information, it is recommended that the dietary goals for individuals with diabetes be the same as for individuals with preexisting CVD, since the two groups appear to have equivalent cardiovascular risk.

In metabolic studies in which energy intake and weight are held constant, diets low in saturated fatty acids and high in either carbohydrate or cis -monounsaturated fatty acids lowered plasma LDL cholesterol equivalently 1 , However, high—monounsaturated fat diets have not been shown to improve fasting plasma glucose or A1C values.

In other studies, when energy intake was reduced, the adverse effects of high-carbohydrate diets were not observed 53 , Individual variability in response to high-carbohydrate diets suggests that the plasma triglyceride response to dietary modification should be monitored carefully, particularly in the absence of weight loss.

Diets high in polyunsaturated fatty acids appear to have effects similar to monounsaturated fatty acids on plasma lipid concentrations 55 , 56 — Very-long-chain n-3 polyunsaturated fatty acid supplements have been shown to lower plasma triglyceride levels in individuals with type 2 diabetes who are hypertriglyceridemic. Although the accompanying small rise in plasma LDL cholesterol is of concern, an increase in HDL cholesterol may offset this concern Glucose metabolism is not likely to be adversely affected.

Very-long-chain n-3 polyunsaturated fatty acid studies in individuals with diabetes have primarily used fish oil supplements. In addition to providing n-3 fatty acids, fish frequently displace high—saturated fat—containing foods from the diet Two or more servings of fish per week with the exception of commercially fried fish filets 63 , 64 can be recommended. Plant sterol and stanol esters block the intestinal absorption of dietary and biliary cholesterol.

A wide range of foods and beverages are now available that contain plant sterols. If these products are used, they should displace, rather than be added to, the diet to avoid weight gain. Soft gel capsules containing plant sterols are also available. 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.

High-protein diets are not recommended as a method for weight loss at this time. Although such diets may produce short-term weight loss and improved 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.

The RDA is 0. Good-quality protein sources are defined as having high PDCAAS protein digestibility—corrected amino acid scoring pattern scores and provide all nine indispensable amino acids. Examples are meat, poultry, fish, eggs, milk, cheese, and soy. In meal planning, protein intake should be greater than 0. A number of studies in healthy individuals and in individuals with type 2 diabetes have demonstrated that glucose produced from ingested protein does not increase plasma glucose concentration but does produce increases in serum insulin responses 1 , Abnormalities in protein metabolism may be caused by insulin deficiency and insulin resistance; however, these are usually corrected with good blood glucose control However, the effects of high-protein diets on long-term regulation of energy intake, satiety, weight, and the ability of individuals to follow such diets long term have not been adequately studied.

Dietary protein and its relationships to hypoglycemia and nephropathy are addressed in later sections. Although numerous studies have attempted to identify the optimal mix of macronutrients for the diabetic diet, it is unlikely that one such combination of macronutrients exists.

The best mix of carbohydrate, protein, and fat appears to vary depending on individual circumstances. For those individuals seeking guidance as to macronutrient distribution in healthy adults, the Dietary Reference Intakes DRIs may be helpful It must be clearly recognized that regardless of the macronutrient mix, total caloric intake must be appropriate to weight management goals. Further, individualization of the macronutrient composition will depend on the metabolic status of the patient e.

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. To reduce risk of nocturnal hypoglycemia in individuals using insulin or insulin secretagogues, alcohol should be consumed with food.

In individuals with diabetes, moderate alcohol consumption when ingested alone has no acute effect on glucose and insulin concentrations but carbohydrate coingested with alcohol as in a mixed drink may raise blood glucose. Abstention from alcohol should be advised for people with a history of alcohol abuse or dependence, women during pregnancy, and people with medical problems such as liver disease, pancreatitis, advanced neuropathy, or severe hypertriglyceridemia.

If individuals choose to use alcohol, intake should be limited to a moderate amount less than one drink per day for adult women and less than two drinks per day for adult men. One alcohol containing beverage is defined as 12 oz beer, 5 oz wine, or 1.

Moderate amounts of alcohol, when ingested with food, have minimal acute effects on plasma glucose and serum insulin concentrations However, carbohydrate coingested with alcohol may raise blood glucose. For individuals using insulin or insulin secretagogues, alcohol should be consumed with food to avoid hypoglycemia.

Evening consumption of alcohol may increase the risk of nocturnal and fasting hypoglycemia, particularly in individuals with type 1 diabetes Occasional use of alcoholic beverages should be considered an addition to the regular meal plan, and no food should be omitted. Excessive amounts of alcohol three or more drinks per day , on a consistent basis, contributes to hyperglycemia In individuals with diabetes, light to moderate alcohol intake one to two drinks per day; 15—30 g alcohol is associated with a decreased risk of CVD The type of alcohol-containing beverage consumed does not appear to make a difference.

There is no clear evidence of benefit from vitamin or mineral supplementation in people with diabetes compared with the general population who do not have underlying deficiencies. Routine supplementation with antioxidants, such as vitamins E and C and carotene, is not advised because of lack of evidence of efficacy and concern related to long-term safety.

Benefit from chromium supplementation in individuals with diabetes or obesity has not been clearly demonstrated and therefore can not be recommended. Uncontrolled diabetes is often associated with micronutrient deficiencies Individuals with diabetes should be aware of the importance of acquiring daily vitamin and mineral requirements from natural food sources and a balanced diet. Health care providers should focus on nutrition counseling rather than micronutrient supplementation in order to reach metabolic control of their patients.

Research including long-term trials is needed to assess the safety and potentially beneficial role of chromium, magnesium, and antioxidant supplements and other complementary therapies in the management of type 2 diabetes 71a , 71b.

In select groups such as the elderly, pregnant or lactating women, strict vegetarians, or those on calorie-restricted diets, a multivitamin supplement may be needed 1. Since diabetes may be a state of increased oxidative stress, there has been interest in antioxidant therapy. Unfortunately, there are no studies examining the effects of dietary intervention on circulating levels of antioxidants and inflammatory biomarkers in diabetic volunteers.

The few small clinical studies involving diabetes and functional foods thought to have high antioxidant potential e. Clinical trial data not only indicate the lack of benefit with respect to glycemic control and progression of complications but also provide evidence of the potential harm of vitamin E, carotene, and other antioxidant supplements 1 , 72 , In addition, available data do not support the use of antioxidant supplements for CVD risk reduction Chromium, potassium, magnesium, and possibly zinc deficiency may aggravate carbohydrate intolerance.

Serum levels can readily detect the need for potassium or magnesium replacement, but detecting deficiency of zinc or chromium is more difficult In the late s, two randomized placebo-controlled studies in China found that chromium supplementation had beneficial effects on glycemia 76 — 78 , but the chromium status of the study populations was not evaluated either at baseline or following supplementation. Data from recent small studies indicate that chromium supplementation may have a role in the management of glucose intolerance, gestational diabetes mellitus GDM , and corticosteroid-induced diabetes 76 — However, other well-designed studies have failed to demonstrate any significant benefit of chromium supplementation in individuals with impaired glucose intolerance or type 2 diabetes 79 , Similarly, a meta-analysis of randomized controlled trials failed to demonstrate any benefit of chromium picolinate supplementation in reducing body weight The FDA concluded that although a small study suggested that chromium picolinate may reduce insulin resistance, the existence of such a relationship between chromium picolinate and either insulin resistance or type 2 diabetes was uncertain http: There is insufficient evidence to demonstrate efficacy of individual herbs and supplements in diabetes management In addition, commercially available products are not standardized and vary in the content of active ingredients.

Herbal preparations also have the potential to interact with other medications Therefore, it is important that health care providers be aware when patients with diabetes are using these products and look for unusual side effects and herb-drug or herb-herb interactions.

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

For individuals using fixed daily insulin doses, carbohydrate intake on a day-to-day basis should be kept consistent with respect to time and amount. For planned exercise, insulin doses can be adjusted.

For unplanned exercise, extra carbohydrate may be needed. The first nutrition priority for individuals requiring insulin therapy is to integrate an insulin regimen into their lifestyle. For individuals receiving basal-bolus insulin therapy, the total carbohydrate content of meals and snacks is the major determinant of bolus insulin doses Insulin-to-carbohydrate ratios can be used to adjust mealtime insulin doses. Several methods can be used to estimate the nutrient content of meals, including carbohydrate counting, the exchange system, and experience-based estimation.

Improvement in A1C without a significant increase in severe hypoglycemia was demonstrated, as were positive effects on quality of life, satisfaction with treatment, and psychological well-being, even though increases in the number of insulin injections and blood glucose tests were necessary. For planned exercise, reduction in insulin dosage is the preferred method to prevent hypoglycemia For unplanned exercise, intake of additional carbohydrate is usually needed.

More carbohydrate is needed for intense activity. A American Diabetes Association statement addresses diabetes MNT for children and adolescents with type 1 diabetes Individuals with type 2 diabetes are encouraged to implement lifestyle modifications that reduce intakes of energy, saturated and trans fatty acids, cholesterol, and sodium and to increase physical activity in an effort to improve glycemia, dyslipidemia, and blood pressure.

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. Healthy lifestyle nutrition recommendations for the general public are also appropriate for individuals with type 2 diabetes.

Because many individuals with type 2 diabetes are overweight and insulin resistant, MNT should emphasize lifestyle changes that result in reduced energy intake and increased energy expenditure through physical activity. Because many individuals also have dyslipidemia and hypertension, reducing saturated and trans fatty acids, cholesterol, and sodium is often desirable.

Therefore, the first nutrition priority is to encourage individuals with type 2 diabetes to implement lifestyle strategies that will improve glycemia, dyslipidemia, and blood pressure. Although there are similarities to those above for type 1 diabetes, MNT recommendations for established type 2 diabetes differ in several aspects from both recommendations for type 1 diabetes and the prevention of diabetes.

MNT progresses from prevention of overweight and obesity, to improving insulin resistance and preventing or delaying the onset of diabetes, and to contributing to improved metabolic control in those with diabetes.

With established type 2 diabetes treated with fixed doses of insulin or insulin secretagogues, consistency in timing and carbohydrate content of meals is important.

However, rapid-acting insulins and rapid-acting insulin secretagogues allow for more flexible food intake and lifestyle as in individuals with type 1 diabetes. Increased physical activity by individuals with type 2 diabetes can lead to improved glycemia, decreased insulin resistance, and a reduction in cardiovascular risk factors, independent of change in body weight.

Resistance training is also effective in improving glycemia and, in the absence of proliferative retinopathy, people with type 2 diabetes can be encouraged to perform resistance exercise three times a week 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. MNT for GDM focuses on food choices for appropriate weight gain, normoglycemia, and absence of ketones. Because GDM is a risk factor for subsequent type 2 diabetes, after delivery, lifestyle modifications aimed at reducing weight and increasing physical activity are recommended.

Prepregnancy MNT includes an individualized prenatal meal plan to optimize blood glucose control. Due to the continuous fetal draw of glucose from the mother, maintaining consistency of times and amounts of food eaten are important to avoidance of hypoglycemia. Plasma glucose monitoring and daily food records provide valuable information for insulin and meal plan adjustments. MNT for GDM primarily involves a carbohydrate-controlled meal plan that promotes optimal nutrition for maternal and fetal health with adequate energy for appropriate gestational weight gain, achievement and maintenance of normoglycemia, and absence of ketosis.

Specific nutrition and food recommendations are determined and subsequently modified based on individual assessment and self-monitoring of blood glucose. A recent large clinical trial reported that treatment of GDM with nutrition therapy, blood glucose monitoring, and insulin therapy as required for glycemic control reduced serious perinatal complications without increasing the rate of cesarean delivery as compared with routine care Maternal health—related quality of life was also improved.

Hypocaloric diets in obese women with GDM can result in ketonemia and ketonuria. Insufficient data are available to determine how such diets affect perinatal outcomes. Daily food records, weekly weight checks, and ketone testing can be used to determine individual energy requirements and whether a woman is undereating to avoid insulin therapy. Carbohydrate should be distributed throughout the day in three small- to moderate-sized meals and two to four snacks.

An evening snack may be needed to prevent accelerated ketosis overnight. Carbohydrate is generally less well tolerated at breakfast than at other meals. Regular physical activity can help lower fasting and postprandial plasma glucose concentrations and may be used as an adjunct to improve maternal glycemia. If insulin therapy is added to MNT, maintaining carbohydrate consistency at meals and snacks becomes a primary goal. Although most women with GDM revert to normal glucose tolerance postpartum, they are at increased risk of GDM in subsequent pregnancies and type 2 diabetes later in life.

Lifestyle modifications after pregnancy aimed at reducing weight and increasing physical activity are recommended, as they reduce the risk of subsequent diabetes 26 , Breast-feeding is recommended for infants of women with preexisting diabetes or GDM; however, successful lactation requires planning and coordination of care In most situations, breast-feeding mothers require less insulin because of the calories expended with nursing.

Lactating women have reported fluctuations in blood glucose related to nursing sessions, often requiring a snack containing carbohydrate before or during breast-feeding 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.

A daily multivitamin supplement may be appropriate, especially for those older adults with reduced energy intake. Physical activity is needed to attenuate loss of lean body mass that can occur with energy restriction. Exercise training can significantly reduce the decline in maximal aerobic capacity that occurs with age, improve risk factors for atherosclerosis, slow the age-related decline in lean body mass, decrease central adiposity, and improve insulin sensitivity—all potentially beneficial for the older adult with diabetes 89 , However, exercise can also pose potential risks such as cardiac ischemia, musculoskeletal injuries, and hypoglycemia in patients treated with insulin or insulin secretagogues.

Reduction of protein intake to 0. MNT that favorably affects cardiovascular risk factors may also have a favorable effect on microvascular complications such as retinopathy and nephropathy.

Progression of diabetes complications may be modified by improving glycemic control, lowering blood pressure, and, potentially, reducing protein intake.

In several studies of subjects with diabetes and microalbuminuria, urinary albumin excretion rate and decline in glomerular filtration were favorably influenced by reduction of protein intake to 0.

Although reduction of protein intake to 0. In individuals with diabetes and macroalbuminuria, reducing protein from all sources to 0. Although several studies have explored the potential benefit of plant proteins in place of animal proteins and specific animal proteins in diabetic individuals with microalbuninuria, the data are inconclusive 1 , Observational data suggest that dyslipidemia may increase albumin excretion and the rate of progression of diabetic nephropathy Elevation of plasma cholesterol in both type 1 and 2 diabetic subjects and plasma triglycerides in type 2 diabetic subjects were predictors of the need for renal replacement therapy Whereas these observations do not confirm that MNT will affect diabetic nephropathy, MNT designed to reduce the risk for CVD may have favorable effects on microvascular complications of diabetes.

For patients with diabetes at risk for CVD, diets high in fruits, vegetables, whole grains, and nuts may reduce the risk. In normotensive and hypertensive individuals, a reduced sodium intake e. In most individuals, a modest amount of weight loss beneficially affects blood pressure.

In the EDIC Epidemiology of Diabetes Interventions and Complications study, the follow-up of the DCCT Diabetes Control and Complications Trial , intensive treatment of type 1 diabetic subjects during the DCCT study period improved glycemic control and significantly reduced the risk of the combined end point of cardiovascular death, myocardial infarction, and stroke Adjustment for A1C explained most of the treatment effect.

The risk reductions obtained with improved glycemia exceeded those that have been demonstrated for other interventions such as cholesterol and blood pressure reductions. There are no large-scale randomized trials to guide MNT recommendations for CVD risk reduction in individuals with type 2 diabetes. However, because CVD risk factors are similar in individuals with and without diabetes, benefits observed in nutrition studies in the general population are probably applicable to individuals with diabetes.

The previous section on dietary fat addresses the need to reduce intake of saturated and trans fatty acids and cholesterol. Hypertension, which is predictive of progression of micro- as well as macrovascular complications of diabetes, can be prevented and managed with interventions including weight loss, physical activity, moderation of alcohol intake, and diets such as DASH Dietary Approaches to Stop Hypertension.

The DASH diet emphasized fruits, vegetables, and low-fat dairy products; included whole grains, poultry, fish, and nuts; and was reduced in fats, red meat, sweets, and sugar-containing beverages 7 , , The effects of lifestyle interventions on hypertension appear to be additive.

Reduction in blood pressure in people with diabetes can occur with a modest amount of weight loss, although there is great variability in response 1 , 7. Regular aerobic physical activity, such as brisk walking, has an antihypertensive effect 7.

Although chronic excessive alcohol intake is associated with an increased risk of hypertension, light to moderate alcohol consumption is associated with reductions in blood pressure 7. Heart failure and peripheral vascular disease are common in individuals with diabetes, but little is known about the role of MNT in treating these complications. Alcohol intake is discouraged in patients at high risk for heart failure.

Ingestion of 15—20 g glucose is the preferred treatment for hypoglycemia, although any form of carbohydrate that contains glucose may be used. In individuals taking insulin or insulin secretagogues, changes in food intake, physical activity, and medication can contribute to the development of hypoglycemia. The acute glycemic response correlates better with the glucose content than with the carbohydrate content of the food 1.

Although pure glucose may be the preferred treatment, any form of carbohydrate that contains glucose will raise blood glucose Adding protein to carbohydrate does not affect the glycemic response and does not prevent subsequent hypoglycemia. Adding fat, however, may retard and then prolong the acute glycemic response.

During hypoglycemia, gastric-emptying rates are twice as fast as during euglycemia and are similar for liquid and solid foods. During acute illnesses, insulin and oral glucose-lowering medications should be continued. During acute illnesses, testing of plasma glucose and ketones, drinking adequate amounts of fluids, and ingesting carbohydrate are all important.

Acute illnesses can lead to the development of hyperglycemia and, in individuals with type 1 diabetes, ketoacidosis. During acute illnesses, with the usual accompanying increases in counterregulatory hormones, the need for insulin and oral glucose-lowering medications continues and often is increased. In adults, ingestion of — g carbohydrate daily 45—50 g every 3—4 h should be sufficient to prevent starvation ketosis 1. Establishing an interdisciplinary team, implementation of MNT, and timely diabetes-specific discharge planning improves the care of patients with diabetes during and after hospitalizations.

Hospitals should consider implementing a diabetes meal-planning system that provides consistency in the carbohydrate content of specific meals. Hyperglycemia in hospitalized patients is common and represents an important marker of poor clinical outcome and mortality in both patients with and without diabetes Optimizing glucose control in these patients is associated with better outcomes An interdisciplinary team is needed to integrate MNT into the overall management plan , Diabetes nutrition self-management education, although potentially initiated in the hospital, is usually best provided in an outpatient or home setting where the individual with diabetes is better able to focus on learning needs , There is no single meal planning system that is ideal for hospitalized patients.

However, it is suggested that hospitals consider implementing a consistent-carbohydrate diabetes meal-planning system , This systems uses meal plans without a specific calorie level but consistency in the carbohydrate content of meals. The carbohydrate contents of breakfast, lunch, dinner, and snacks may vary, but the day-to-day carbohydrate content of specific meals and snacks is kept constant , Special nutrition issues include liquid diets, surgical diets, catabolic illnesses, and enteral or parenteral nutrition , Liquids should not be sugar free.

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