2 page summary

Nutrition Recommendations and Interventions for Diabetes A position statement of the American Diabetes Association

AMERICAN DIABETES ASSOCIATION

M edical nutrition therapy (MNT) is important in preventing diabetes, managing existing diabetes, and

preventing, or at least slowing, the rate of development of diabetes complications. It is, therefore, important at all levels of di- abetes prevention (see Table 1). MNT is also an integral component of diabetes self-management education (or training). This position statement provides evi- dence-based recommendations and inter- ventions for diabetes MNT. The previous position statement with accompanying technical review was published in 2002 (1) and modified slightly in 2004 (2). This statement updates previous position statements, focuses on key references published since the year 2000, and uses grading according to the level of evidence available based on the American Diabetes Association evidence-grading system. Since overweight and obesity are closely linked to diabetes, particular attention is paid to this area of MNT.

The goal of these recommendations is to make people with diabetes and health care providers aware of beneficial nutri- tion interventions. This requires the use of the best available scientific evidence while taking into account treatment goals, strategies to attain such goals, and changes individuals with diabetes are willing and able to make. Achieving nu- trition-related goals requires a coordi- nated team effort that includes the person with diabetes and involves him or her in the decision-making process. It is recom- mended that a registered dietitian, knowl- edgeable and skilled in MNT, be the team member who plays the leading role in providing nutrition care. However, it is

important that all team members, includ- ing physicians and nurses, be knowledge- a b l e a b o u t M N T a n d s u p p o r t i t s implementation.

MNT, as illustrated in Table 1, plays a role in all three levels of diabetes-related prevention targeted by the U.S. Depart- ment of Health and Human Services. Pri- mary prevention interventions seek to delay or halt the development of diabetes. This involves public health measures to reduce the prevalence of obesity and in- cludes MNT for individuals with pre- diabetes. Secondary and tertiary prevention interventions include MNT for individuals with diabetes and seek to prevent (sec- ondary) or control (tertiary) complica- tions of diabetes.

GOALS OF MNT FOR PREVENTION AND TREATMENT OF DIABETES

Goals of MNT that apply to individuals at risk for diabetes or with pre-diabetes To decrease the risk of diabetes and car- diovascular disease (CVD) by promoting healthy food choices and physical activity leading to moderate weight loss that is maintained.

Goals of MNT that apply to individuals with diabetes 1) Achieve and maintain

● Blood glucose levels in the normal range or as close to normal as is safely possible

● A lipid and lipoprotein profile that re- duces the risk for vascular disease

● Blood pressure levels in the normal

range or as close to normal as is safely possible

2) To prevent, or at least slow, the rate of development of the chronic complica- tions of diabetes by modifying nutrient intake and lifestyle 3) To address individual nutrition needs, taking into account personal and cultural preferences and willingness to change 4) To maintain the pleasure of eating by only limiting food choices when indicated by scientific evidence

Goals of MNT that apply to specific situations 1) For youth with type 1 diabetes, youth with type 2 diabetes, pregnant and lactat- ing women, and older adults with diabe- tes, to meet the nutritional needs of these unique times in the life cycle. 2) For individuals treated with insulin or insulin secretagogues, to provide self- management training for safe conduct of exercise, including the prevention and treatment of hypoglycemia, and diabetes treatment during acute illness.

EFFECTIVENESS OF MNT

Recommendations ● Individuals who have pre-diabetes or

diabetes should receive individualized MNT; such therapy is best provided by a registered dietitian familiar with the components of diabetes MNT. (B)

● Nutrition counseling should be sensi- tive to the personal needs, willingness to change, and ability to make changes of the individual with pre-diabetes or diabetes. (E)

Clinical trials/outcome studies of MNT have reported decreases in HbA1c (A1C) of �1% in type 1 diabetes and 1–2% in type 2 diabetes, depending on the duration of diabetes (3,4). Meta- analysis of studies in nondiabetic, free- living subjects and expert committees report that MNT reduces LDL cholesterol by 15–25 mg/dl (5,6). After initiation of MNT, improvements were apparent in 3– 6 months. Meta-analysis and expert committees also support a role for lifestyle modification in treating hypertension (7,8).

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

Originally approved 2006. Revised 2007. Writing panel: John P. Bantle (Co-Chair), Judith Wylie-Rosett (Co-Chair), Ann L. Albright, Caroline M.

Apovian, Nathaniel G. Clark, Marion J. Franz, Byron J. Hoogwerf, Alice H. Lichtenstein, Elizabeth Mayer- Davis, Arshag D. Mooradian, and Madelyn L. Wheeler.

Abbreviations: CHD, coronary heart disease; CKD, chronic kidney disease; CVD, cardiovascular disease; DPP, Diabetes Prevention Program; FDA, Food and Drug Administration; GDM, gestational diabetes mel- litus; MNT, medical nutrition therapy; RDA, recommended dietary allowance; USDA, U.S. Department of Agriculture.

DOI: 10.2337/dc08-S061 © 2008 by the American Diabetes Association.

P O S I T I O N S T A T E M E N T

DIABETES CARE, VOLUME 31, SUPPLEMENT 1, JANUARY 2008 S61

ENERGY BALANCE, OVERWEIGHT, AND OBESITY

Recommendations ● In overweight and obese insulin-

resistant individuals, modest weight loss has been shown to improve insulin resistance. Thus, weight loss is recom- mended for all such individuals who have or are at risk for diabetes. (A)

● For weight loss, either low-carbohy- drate or low-fat calorie-restricted diets may be effective in the short term (up to 1 year). (A)

● For patients on low-carbohydrate diets, monitor lipid profiles, renal function, and protein intake (in those with ne- phropathy), and adjust hypoglycemic therapy as needed. (E)

● Physical activity and behavior modifi- cation are important components of weight loss programs and are most helpful in maintenance of weight loss. (B)

● Weight loss medications may be con- sidered in the treatment of overweight and obese individuals with type 2 dia- betes and can help achieve a 5–10% weight loss when combined with life- style modification. (B)

● Bariatric surgery may be considered for some individuals with type 2 diabetes and BMI �35 kg/m2 and can result in marked improvements in glycemia. The long-term benefits and risks of bariatric surgery in individuals with

pre-diabetes or diabetes continue to be studied. (B)

The importance of controlling body weight in reducing risks related to diabe- tes is of great importance. Therefore, these nutrition recommendations start by considering energy balance and weight loss strategies. The National Heart, Lung, and Blood Institute guidelines define overweight as BMI �25 kg/m2 and obe- sity as BMI �30 kg/m2 (9). The risk of comorbidity associated with excess adi- pose tissue increases with BMIs in this range and above. However, clinicians should be aware that in some Asian pop- ulations, the proportion of people at high risk of type 2 diabetes and CVD is signif- icant at BMIs of �23 kg/m2 (10). Visceral body fat, as measured by waist circumfer- ence �35 inches in women and �40 inches in men, is used in conjunction with BMI to assess risk of type 2 diabetes and CVD (Table 2) (9). Lower waist cir- cumference cut points (�31 inches in women, �35 inches in men) may be ap- propriate for Asian populations (11).

Because of the effects of obesity on insulin resistance, weight loss is an im- portant therapeutic objective for individ- uals with pre-diabetes or diabetes (12). However, long-term weight loss is diffi- cult for most people to accomplish. This is probably because the central nervous sys- tem plays an important role in regulating energy intake and expenditure. Short- term studies have demonstrated that

moderate weight loss (5% of body weight) in subjects with type 2 diabetes is associ- ated with decreased insulin resistance, improved measures of glycemia and li- pemia, and reduced blood pressure (13). Longer-term studies (�52 weeks) using pharmacotherapy for weight loss in adults with type 2 diabetes produced modest re- ductions in weight and A1C (14), al- though improvement in A1C was not seen in all studies (15,16). Look AHEAD (Ac- tion for Health in Diabetes) is a large Na- tional Institutes of Health–sponsored clinical trial designed to determine if long-term weight loss will improve glyce- mia and prevent cardiovascular events (17). When completed, this study should provide insight into the effects of long- term weight loss on important clinical outcomes.

Evidence demonstrates that struc- tured, intensive lifestyle programs involv- ing participant education, individualized counseling, reduced dietary energy and fat (�30% of total energy) intake, regular physical activity, and frequent participant contact are necessary to produce long- term weight loss of 5–7% of starting weight (1). The role of lifestyle modifica- tion in the management of weight and type 2 diabetes was recently reviewed (13). Although structured lifestyle pro- grams 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 (18).

Exercise and physical activity, by themselves, have only a modest weight loss effect. However, exercise and physi- cal activity are to be encouraged because they improve insulin sensitivity indepen- dent 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 ap- proaches may be most useful as an ad- junct to other weight loss strategies.

Standard weight loss diets provide

Table 1—Nutrition and MNT

Primary prevention to prevent diabetes: Secondary prevention to prevent complications: Tertiary prevention to prevent morbidity and mortality: ● Use MNT and public health interventions in those with obesity and pre-diabetes

● Use MNT for metabolic control of diabetes ● Use MNT to delay and manage complications of diabetes

Table 2—Classification of overweight and obesity by BMI, waist circumference, and associ- ated disease risk

BMI (kg/m2) Obesity

class

Disease risk*

WC: men �40 inches; women �35 inches

WC: men �40 inches; women

�35 inches

Underweight �18.5 Normal 18.5–24.9 Overweight 25.0–29.9 Increased High Obesity 30.0–34.9 I High Very high

35.0–39.9 II Very high Very high Extreme obesity �40 III Extremely high Extremely high

*Disease risk for type 2 diabetes, hypertension, and CVD. Adapted from ref. 9. WC, waist circumference.

Nutrition recommendations and interventions

S62 DIABETES CARE, VOLUME 31, SUPPLEMENT 1, JANUARY 2008

500 –1,000 fewer calories than estimated to be necessary for weight maintenance and initially result in a loss of �1–2 lb/ week. Although many people can lose some weight (as much as 10% of initial weight in �6 months) with such diets, without continued support and follow- up, people usually regain the weight they have lost.

The optimal macronutrient distri- bution 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-carbohy- drate diets lost more weight at 6 months than subjects on low-fat diets (19,20). Another study of overweight women randomized to one of four diets showed significantly more weight loss at 12 months with the Atkins low-carbohy- drate diet than with higher-carbohy- drate 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 se- rum triglyceride and HDL cholesterol were more favorable with the low- carbohydrate diets. In one study, those subjects with type 2 diabetes demon- strated a greater decrease in A1C with a low-carbohydrate diet than with a low- fat diet (20). A recent meta-analysis s h o w e d t h a t a t 6 m o n t h s , l o w - carbohydrate diets were associated with greater improvements in triglyceride and HDL cholesterol concentrations than low-fat diets; however, LDL cho- lesterol was significantly higher on the low-carbohydrate diets (21). Further research is needed to determine the long-term efficacy and safety of low- carbohydrate diets (13). The recom- mended dietary allowance (RDA) for digestible carbohydrate is 130 g/day and is based on providing adequate glu- cose as the required fuel for the central nervous system without reliance on glu- cose production from ingested protein or fat (22). Although brain fuel needs can be met on lower-carbohydrate di- ets, long-term metabolic effects of very- low-carbohydrate diets are unclear, and such diets eliminate many foods that are important sources of energy, fiber, vita- mins, and minerals and are important in dietary palatability (22).

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 sig- nificant weight loss. Meal replacements are an important part of the Look AHEAD weight loss intervention (17). However, meal replacement therapy must be con- tinued indefinitely if weight loss is to be maintained.

Very-low-calorie diets provide �800 calories daily and produce substantial weight loss and rapid improvements in glycemia and lipemia in individuals with type 2 diabetes. When very-low-calorie diets are stopped and self-selected meals are reintroduced, weight regain is com- mon. Thus, very-low-calorie diets appear to have limited utility in the treatment of type 2 diabetes and should only be con- sidered in conjunction with a structured weight loss program.

The available data suggest that weight loss medications may be useful in the treatment of overweight individuals with and at risk for type 2 diabetes and can help achieve a 5–10% weight loss when combined with lifestyle change (14). Ac- cording to their labels, these medications should only be used in people with dia- betes who have BMI �27.0 kg/m2.

Gastric reduction surgery can be an effective weight loss treatment for obesity and may be considered in people with di- abetes who have BMI �35 kg/m2. A meta- analysis of studies of bariatric surgery reported that 77% of individuals with type 2 diabetes had complete resolution of diabetes (normalization of blood glu- cose levels in the absence of medications), and diabetes was resolved or improved in 86% (23). In the Swedish Obese Subjects study, a 10-year follow-up of individuals undergoing bariatric surgery, 36% of sub- jects with diabetes had resolution of dia- betes compared with 13% of matched control subjects (24). All cardiovascular risk factors except hypercholesterolemia improved in the surgical patients.

NUTRITION RECOMMENDATIONS AND INTERVENTIONS FOR THE PREVENTION OF DIABETES (PRIMARY PREVENTION)

Recommendations ● Among individuals at high risk for de-

veloping type 2 diabetes, structured programs that emphasize lifestyle changes that include moderate weight loss (7% body weight) and regular physical activity (150 min/week), with dietary strategies including reduced calories and reduced intake of dietary

fat, can reduce the risk for developing diabetes and are therefore recom- mended. (A)

● Individuals at high risk for type 2 dia- betes should be encouraged to achieve the U.S. Department of Agriculture (USDA) recommendation for dietary fi- ber (14 g fiber/1,000 kcal) and foods containing whole grains (one-half of grain intake). (B)

● There is not sufficient, consistent infor- mation 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 encour- aged. (E)

● Observational studies report that mod- erate alcohol intake may reduce the risk for diabetes, but the data do not sup- port recommending alcohol consump- tion to individuals at risk of diabetes. (B)

● No nutrition recommendation can be made for preventing type 1 diabetes. (E)

● Although there are insufficient data at present to warrant any specific recom- mendations for prevention of type 2 di- abetes in youth, it is reasonable to apply approaches demonstrated to be effec- tive in adults, as long as nutritional needs for normal growth and develop- ment are maintained. (E)

The importance of preventing type 2 diabetes is highlighted by the substan- tial worldwide increase in the preva- lence of diabetes in recent years. Genetic susceptibility appears to play a powerful role in the occurrence of type 2 diabetes. However, given that popu- lation gene pools shift very slowly over time, the current epidemic of diabetes likely reflects changes in lifestyle lead- ing to diabetes. Lifestyle changes char- acterized by increased energy intake and decreased physical activity appear to have together promoted overweight and obesity, which are strong risk fac- tors 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 life- style changes alone or with adjunctive therapies such as medication or bariatric- surgery (see ENERGY BALANCE section) (1). Moreover, both moderate-intensity and vigorous exercise can improve insulin

Position Statement

DIABETES CARE, VOLUME 31, SUPPLEMENT 1, JANUARY 2008 S63

sensitivity, independent of weight loss, and reduce risk for type 2 diabetes (1).

Clinical trial data from both the Finnish Diabetes Prevention study (25) and the Diabetes Prevention Program (DPP) in the U.S (26) strongly support the potential for moderate weight loss to reduce the risk for type 2 diabetes. The lifestyle intervention in both trials em- phasized lifestyle changes that included moderate weight loss (7% of body weight) and regular physical activity (150 min/week), with dietary strategies to reduce intake of fat and calories. In the DPP, subjects in the lifestyle inter- vention group reported dietary fat in- takes of �34% of energy at baseline and 28% of energy after 1 year of interven- tion (27). A majority of subjects in the lifestyle intervention group met the physical activity goal of 150 min/week of moderate physical activity (26,28). In addition to preventing diabetes, the DPP lifestyle intervention improved several CVD risk factors, including dsylipidemia, hypertension, and in- flammatory markers (29,30). The DPP analysis indicated that lifestyle inter- vention was cost-effective (31), but other analyses suggest that the expected costs needed to be reduced (32).

Both the Finnish Diabetes Preven- tion study and the DPP focused on re- duced intake of calories (using reduced dietary fat as a dietary intervention). Of note, reduced intake of fat, particularly saturated fat, may reduce risk for diabe- tes by producing an energy-indepen- dent improvement in insulin resistance (1,33,34), as well as by promoting weight loss. It is possible that reduction in other macronutrients (e.g., carbohy- drates) would also be effective in pre- vention of diabetes through promotion of weight loss; however, clinical trial data on the efficacy of low-carbohydrate diets for primary prevention of type 2 diabetes are not available.

Several studies have provided evi- dence for reduced risk of diabetes with increased intake of whole grains and di- etary fiber (1,35–37). Whole grain– containing foods have been associated with improved insulin sensitivity, inde- pendent of body weight, and dietary fiber has been associated with improved insu- lin sensitivity and improved ability to se- crete insulin adequately to overcome insulin resistance (38). There is debate as to the potential role of low– glycemic in- dex and – glycemic load diets in preven- tion of type 2 diabetes. Although some

studies have demonstrated an association between glycemic load and risk for diabe- tes, other studies have been unable to confirm this relationship, and a recent re- port showed no association of glycemic index/glycemic load with insulin sensitiv- ity (39).

Thus, there is not sufficient, consis- tent information to conclude that low– glycemic load diets reduce risk for diabetes. Prospective randomized clinical trials will be necessary to resolve this is- sue. Nevertheless, low– glycemic index foods that are rich in fiber and other im- portant nutrients are to be encouraged. A 2004 American Diabetes Association statement reviewed this issue in depth (40), and issues related to the role of gly- cemic index and glycemic load in dia- betes 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 (44). However, heavy con- sumption of alcohol (greater than three drinks per day), may be associated with increased incidence of diabetes (42). If al- cohol is consumed, recommendations from the 2005 USDA Dietary Guidelines for Americans suggest no more than one drink per day for women and two drinks per day for men (45).

Although selected micronutrients may affect glucose and insulin metabo- lism, to date, there are no convincing data that document their role in the develop- ment of diabetes.

Diabetes in youth 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 dia- betes, particularly in minority adoles- cents. Although there are insufficient data at present to warrant any specific recom- mendations 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 inter- ventions are ongoing in children.

NUTRITION RECOMMENDATIONS FOR THE MANAGEMENT OF DIABETES (SECONDARY PREVENTION)

Carbohydrate in diabetes management

Recommendations ● A dietary pattern that includes carbo-

hydrate from fruits, vegetables, whole grains, legumes, and low-fat milk is en- couraged for good health. (B)

● Monitoring carbohydrate, whether by carbohydrate counting, exchanges, or experienced-based estimation remains a key strategy in achieving glycemic control. (A)

● The use of glycemic index and load may provide a modest additional benefit over that observed when total carbohy- drate is considered alone. (B)

● Sucrose-containing foods can be sub- stituted 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. (A)

● As for the general population, people with diabetes are encouraged to con- sume a variety of fiber-containing foods. However, evidence is lacking to recommend a higher fiber intake for people with diabetes than for the pop- ulation as a whole. (B)

● Sugar alcohols and nonnutritive sweet- eners are safe when consumed within the daily intake levels established by the Food and Drug Administration (FDA). (A)

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 re- duce postprandial blood glucose excur- sions are important in this regard, since dietary carbohydrate is the major deter- minant of postprandial glucose levels. Low-carbohydrate diets might seem to be a logical approach to lowering postpran- dial glucose. However, foods that contain carbohydrate are important sources of en- ergy, fiber, vitamins, and minerals and are important in dietary palatability. There- fore, these foods are important compo- nents of the diet for individuals with diabetes. Issues related to carbohydrate and glycemia have previously been exten- sively reviewed in American Diabetes Association reports and nutrition recom-

Nutrition recommendations and interventions

S64 DIABETES CARE, VOLUME 31, SUPPLEMENT 1, JANUARY 2008

mendations for the general public (1,2, 22,40,45).

Blood glucose concentration follow- ing 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 (40). Insu- lin secretory response normally maintains blood glucose in a narrow range, but in individuals with diabetes, defects in insu- lin action, insulin secretion, or both im- pair regulation of postprandial glucose in response to dietary carbohydrate. Both the quantity and the type or source of car- bohydrates found in foods influence post- prandial glucose levels. Amount and type of carbohydrate. A 2004 ADA statement addressed the ef- fects of the amount and type of carbohy- drate in diabetes management (40). As noted previously, the RDA for carbohy- drate (130 g/day) is an average minimum requirement (22). There are no trials spe- cifically in patients with diabetes restrict- ing total carbohydrate to �130 g/day. However, 1-year follow-up data from a small weight-loss trial (20) indicate, among the subset with diabetes, that the reduction in fasting glucose was 21 mg/dl (1.17 mmol/l) and 28 mg/dl (1.55 mmol/l) for the low-carbohydrate and low-fat diets, respectively, with no signif- icant difference for change in A1C levels. The 1-year follow-up data also indicate that the macronutrient composition of the treatment groups only differed with re- spect to carbohydrate intake (mean intake of 230 vs. 120 g). Thus, questions about the long-term effects on intake and me- tabolism, as well as safety, need further research.

The amount of carbohydrate ingested is usually the primary determinant of postprandial response, but the type of car- bohydrate also affects this response. In- trinsic 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 de- gree 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 in- sulin, and degree of insulin resistance.

The glycemic index of foods was de- veloped to compare the postprandial re- sponses to constant amounts of different carbohydrate-containing foods (46). 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 50-g car- bohydrate portion) divided by the re- sponse to a reference food (usually glucose or white bread). The glycemic loads of foods, meals, and diets are calcu- lated by multiplying the glycemic index of the constituent foods by the amounts of carbohydrate in each food and then total- ing 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. Fi- ber, fructose, lactose, and fat are dietary constituents that tend to lower glycemic response. Potential methodological prob- lems with the glycemic index have been noted (47).

Several randomized clinical trials have reported that low– glycemic index diets reduce glycemia in diabetic subjects, but other clinical trials have not con- firmed this effect (40). Moreover, the variability in responses to specific carbo- hydrate-containing food is a concern (48). Nevertheless, a recent meta-analysis of low– glycemic index diet trials in dia- betic subjects showed that such diets pro- duced a 0.4% decrement in A1C when compared with high– glycemic index di- ets (49). However, it appears that most individuals already consume a moderate– glycemic index diet (39,50). Thus, it ap- pears 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 impor- tant to match doses of insulin and insulin secretagogues to the carbohydrate con- tent 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 dem- onstrated that one method of assessing the relationship between carbohydrate in- take and blood glucose response is better than other methods. Fiber. As for the general population, people with diabetes are encouraged to choose a variety of fiber-containing foods such as legumes, fiber-rich cereals (�5 g fiber/serving), fruits, vegetables, and whole grain products because they pro-

vide vitamins, minerals, and other sub- stances important for good health. Moreover, there are data suggesting that consuming a high-fiber diet (�50 g fiber/ day) reduces glycemia in subjects with type 1 diabetes and glycemia, hyperinsu- linemia, and lipemia in subjects with type 2 diabetes (1). Palatability, limited food choices, and gastrointestinal side effects are potential barriers to achieving such high-fiber intakes. However, increased fi- ber intake appears to be desirable for peo- ple with diabetes, and a first priority might be to encourage them to achieve the fiber intake goals set for the general pop- ulation of 14 g/1,000 kcal (22). Sweeteners. 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 hyperglyce- mia. Sucrose can be substituted for other carbohydrate sources in the meal plan or, if added to the meal plan, adequately cov- ered 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 re- sponse when it replaces sucrose or starch in the diet; however, this benefit is tem- pered by concern that fructose may ad- versely affect plasma lipids (1). Therefore, the use of added fructose as a sweetening agent in the diabetic diet is not recom- mended. There is, however, no reason to recommend that people with diabetes avoid naturally occurring fructose in fruits, vegetables, and other foods. Fruc- tose from these sources usually accounts for only 3– 4% of energy intake.

Reduced calorie sweeteners approved by the FDA include sugar alcohols (poly- ols) such as erythritol, isomalt, lactitol, maltitol, mannitol, sorbitol, xylitol, taga- tose, and hydrogenated starch hydroly- sates. 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). Sugar alcohols contain, on average, about 2 cal- ories/g (one-half the calories of other sweeteners such as sucrose). When calcu- lating carbohydrate content of foods con- taining sugar alcohols, subtraction of half

Position Statement

DIABETES CARE, VOLUME 31, SUPPLEMENT 1, JANUARY 2008 S65

the sugar alcohol grams from total carbo- hydrate grams is appropriate. Use of sugar alcohols as sweeteners reduces the risk of dental caries. However, there is no evi- dence that the amounts of sugar alcohols likely to be consumed will reduce glyce- mia, energy intake, or weight. The use of sugar alcohols appears to be safe; how- ever, they may cause diarrhea, especially in children.

The FDA has approved five nonnutri- tive sweeteners for use in the U.S. These are acesulfame potassium, aspartame, neotame, saccharin, and sucralose. Before being allowed on the market, all under- went rigorous scrutiny and were shown to be safe when consumed by the public, in- cluding people with diabetes and women during pregnancy. Clinical studies in- volving subjects without diabetes provide no indication that nonnutritive sweeten- ers in foods will cause weight loss or weight gain (51). Resistant-starch/high-amylose foods. It has been proposed that foods contain- ing resistant starch (starch physically en- closed within intact cell structures as in some legumes, starch granules as in raw potato, and retrograde amylose from plants modified by plant breeding to in- crease amylose content) or high-amylose foods, such as specially formulated corn- starch, may modify postprandial glycemic response, prevent hypoglycemia, and re- duce hyperglycemia. However, there are no published long-term studies in sub- jects with diabetes to prove benefit from the use of resistant starch.

Dietary fat and cholesterol in diabetes management

Recommendations ● Limit saturated fat to �7% of total cal-

ories. (A) ● Intake of trans fat should be minimized.

(E) ● In individuals with diabetes, limit di-

etary cholesterol to �200 mg/day. (E) ● Two or more servings of fish per week

(with the exception of commercially fried fish filets) provide n-3 polyunsat- urated fatty acids and are recom- mended. (B)

The primary goal with respect to di- etary fat in individuals with diabetes is to limit saturated fatty acids, trans fatty ac- ids, and cholesterol intakes so as to re- duce risk for CVD. Saturated and trans fatty acids are the principal dietary deter- minants of plasma LDL cholesterol. In

nondiabetic individuals, reducing satu- rated and trans fatty acids and cholesterol intakes decreases plasma total and LDL cholesterol. Reducing saturated fatty ac- ids may also reduce HDL cholesterol. Im- portantly, the ratio of LDL cholesterol to HDL cholesterol is not adversely affected. Studies in individuals with diabetes dem- onstrating the effects of specific percent- ages of dietary saturated and trans fatty acids and specific amounts of dietary cho- lesterol 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 preex- isting CVD, since the two groups appear to have equivalent cardiovascular risk. Thus, saturated fatty acids �7% of total energy, minimal intake of trans fatty ac- ids, and cholesterol intake �200 mg daily are recommended.

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-monounsat- urated fatty acids lowered plasma LDL cholesterol equivalently (1,52). The high- carbohydrate diets (�55% of total energy from carbohydrate) increased postpran- dial plasma glucose, insulin, and triglyc- erides when compared with high– monounsaturated fat diets. 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 ad- verse effects of high-carbohydrate diets were not observed (53,54). Individual v a r i a b i l i t y i n r e s p o n s e t o h i g h - carbohydrate diets suggests that the plasma triglyceride response to dietary modification should be monitored care- fully, 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 (55–58). A modified Mediterranean diet, in which polyunsat- urated fatty acids were substituted for monounsaturated fatty acids, reduced overall mortality in elderly Europeans by 7% (59). Very-long-chain n-3 polyunsat- urated 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 (60). 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. Consumption of �-3 fatty acids from fish or from sup- plements has been shown to reduce ad- verse CVD outcomes, but the evidence for �-linolenic acid is sparse and inconclu- sive (61). In addition to providing n-3 fatty acids, fish frequently displace high– saturated fat– containing foods from the diet (62). Two or more servings of fish per week (with the exception of com- mercially fried fish filets) (63,64) can be recommended.

Plant sterol and stanol esters block the intestinal absorption of dietary and biliary cholesterol. In the general public and in individuals with type 2 diabetes (65), intake of �2 g/day plant sterols and stanols has been shown to lower plasma total and LDL cholesterol. A wide range of foods and beverages are now available that contain plant sterols. If these prod- ucts 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.

Protein in diabetes management

Recommendations ● For individuals with diabetes and nor-

mal renal function, there is insufficient evidence to suggest that usual protein intake (15–20% of energy) should be modified. (E)

● In individuals with type 2 diabetes, in- gested protein can increase insulin re- sponse without increasing plasma glucose concentrations. Therefore, pro- tein should not be used to treat acute or prevent nighttime hypoglycemia. (A)

● High-protein diets are not recom- mended as a method for weight loss at this time. The long-term effects of pro- tein intake �20% of calories on diabe- tes management and its complications are unknown. Although such diets may produce short-term weight loss and improved glycemia, it has not been es- tablished that these benefits are main- tained long term, and long-term effects on kidney function for persons with di- abetes are unknown. (E)

The Dietary Reference Intakes’ ac- ceptable macronutrient distribution range for protein is 10 –35% of energy in- take, with 15% being the average adult intake in the U.S. and Canada (22). The RDA is 0.8 g good-quality protein � kg

Nutrition recommendations and interventions

S66 DIABETES CARE, VOLUME 31, SUPPLEMENT 1, JANUARY 2008

body wt�1 � day�1 (on average, �10% of calories) (22). Good-quality protein sources are defined as having high PD- CAAS (protein digestibility– corrected amino acid scoring pattern) scores and provide all nine indispensable amino ac- ids. Examples are meat, poultry, fish, eggs, milk, cheese, and soy. Sources not in the “good” category include cereals, grains, nuts, and vegetables. In meal plan- ning, protein intake should be greater than 0.8 g � kg�1 � day�1 to account for mixed protein quality in foods.

The dietary intake of protein for indi- viduals with diabetes is similar to that of the general public and usually does not exceed 20% of energy intake. 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 re- sponses (1,66). Abnormalities in protein metabolism may be caused by insulin de- ficiency and insulin resistance; however, these are usually corrected with good blood glucose control (67).

Small, short-term studies in diabetes suggest that diets with protein content �20% of total energy reduce glucose and insulin concentrations, reduce appetite, and increase satiety (68,69). 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 ad- dressed in later sections.

Optimal mix of macronutrients Although numerous studies have at- tempted 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 circum- stances. For those individuals seeking guidance as to macronutrient distribution in healthy adults, the Dietary Reference Intakes (DRIs) may be helpful (22). It must be clearly recognized that regardless of the macronutrient mix, total caloric in- take must be appropriate to weight man- agement goals. Further, individualization of the macronutrient composition will de- pend on the metabolic status of the pa- tient (e.g., lipid profile).

Alcohol in diabetes management

Recommendations ● 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). (E)

● To reduce risk of nocturnal hypoglyce- mia in individuals using insulin or in- sulin secretagogues, alcohol should be consumed with food. (E)

● In individuals with diabetes, moderate alcohol consumption (when ingested alone) has no acute effect on glucose and insulin concentrations but carbo- hydrate coingested with alcohol (as in a mixed drink) may raise blood glucose. (B)

Abstention from alcohol should be advised for people with a history of alco- hol abuse or dependence, women during pregnancy, and people with medical problems such as liver disease, pancreati- tis, advanced neuropathy, or severe hy- pertriglyceridemia. 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 1.5 oz distilled spirits. Each contains �15 g alcohol.

Moderate amounts of alcohol, when ingested with food, have minimal acute effects on plasma glucose and serum in- sulin concentrations (42). However, car- bohydrate 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 (70). Oc- casional use of alcoholic beverages should be considered an addition to the regular meal plan, and no food should be omit- ted. Excessive amounts of alcohol (three or more drinks per day), on a consistent basis, contributes to hyperglycemia (42).

In individuals with diabetes, light to moderate alcohol intake (one to two drinks per day; 15–30 g alcohol) is asso- ciated with a decreased risk of CVD (42). The reduction in CVD does not appear to be due to an increase in plasma HDL cho- lesterol. The type of alcohol-containing beverage consumed does not appear to make a difference.

Micronutrients in diabetes management

Recommendations ● There is no clear evidence of benefit

from vitamin or mineral supplementa- tion in people with diabetes (compared with the general population) who do not have underlying deficiencies. (A)

● Routine supplementation with antioxi- dants, such as vitamins E and C and carotene, is not advised because of lack of evidence of efficacy and concern re- lated to long-term safety. (A)

● Benefit from chromium supplementa- tion in individuals with diabetes or obe- sity has not been clearly demonstrated and therefore can not be recom- mended. (E)

Uncontrolled diabetes is often associ- ated with micronutrient deficiencies (71). Individuals with diabetes should be aware of the importance of acquiring daily vita- min and mineral requirements from nat- ural food sources and a balanced diet. Health care providers should focus on nu- trition counseling rather than micronutri- ent supplementation in order to reach metabolic control of their patients. Re- search 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 manage- ment of type 2 diabetes (71a,71b). In se- lect groups such as the elderly, pregnant or lactating women, strict vegetarians, or those on calorie-restricted diets, a multi- vitamin supplement may be needed (1). Antioxidants in diabetes management. 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 di- etary intervention on circulating levels of antioxidants and inflammatory biomark- ers in diabetic volunteers. The few small clinical studies involving diabetes and functional foods thought to have high an- tioxidant potential (e.g., tea, cocoa, cof- fee) are inconclusive. Clinical trial data not only indicate the lack of benefit with respect to glycemic control and progres- sion of complications but also provide ev- idence of the potential harm of vitamin E, carotene, and other antioxidant supple- ments (1,72,73). In addition, available data do not support the use of antioxidant supplements for CVD risk reduction (74).

Position Statement

DIABETES CARE, VOLUME 31, SUPPLEMENT 1, JANUARY 2008 S67

Chromium, other minerals, and herbs in diabetes management. Chromium, potassium, magnesium, and possibly zinc deficiency may aggravate carbohydrate intolerance. Serum levels can readily de- tect the need for potassium or magnesium replacement, but detecting deficiency of zinc or chromium is more difficult (75). In the late 1990s, two randomized place- bo-controlled studies in China found that chromium supplementation had benefi- cial effects on glycemia (76 –78), but the chromium status of the study populations was not evaluated either at baseline or fol- lowing supplementation. Data from re- cent small studies indicate that chromium supplementation may have a role in the management of glucose intolerance, ges- tational diabetes mellitus (GDM), and corticosteroid-induced diabetes (76 –78). However, other well-designed studies have failed to demonstrate any significant benefit of chromium supplementation in individuals with impaired glucose intol- erance or type 2 diabetes (79,80). Simi- larly, a meta-analysis of randomized controlled trials failed to demonstrate any benefit of chromium picolinate supple- mentation in reducing body weight (81). The FDA concluded that although a small study suggested that chromium picoli- nate may reduce insulin resistance, the existence of such a relationship between chromium picolinate and either insulin resistance or type 2 diabetes was uncer- tain (http:/www.cfsan.fda.gov/�dms/ qhccr.html).

There is insufficient evidence to dem- onstrate efficacy of individual herbs and supplements in diabetes management (82). In addition, commercially available products are not standardized and vary in the content of active ingredients. Herbal preparations also have the potential to in- teract with other medications (83). There- fore, it is important that health care providers be aware when patients with di- abetes are using these products and look for unusual side effects and herb-drug or herb-herb interactions

NUTRITION INTERVENTIONS FOR SPECIFIC POPULATIONS

Nutrition interventions for type 1 diabetes

Recommendations ● For individuals with type 1 diabetes,

insulin therapy should be integrated

into an individual’s dietary and physi- cal activity pattern. (E)

● 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. (A)

● 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. (C)

● For planned exercise, insulin doses can be adjusted. For unplanned exercise, extra carbohydrate may be needed. (E)

The first nutrition priority for indi- viduals requiring insulin therapy is to in- tegrate an insulin regimen into their lifestyle. With the many insulin options now available, an appropriate insulin regi- men can usually be developed to conform to an individual’s preferred meal routine, food choices, and physical activity pattern. For individuals receiving basal-bolus in- sulin therapy, the total carbohydrate con- tent of meals and snacks is the major determinant of bolus insulin doses (84). 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 sys- tem, and experience-based estimation. The DAFNE (Dose Adjustment for Nor- mal Eating) study (85) demonstrated that patients can learn how to use glucose test- ing to better match insulin to carbohy- drate intake. Improvement in A1C without a significant increase in severe hypoglycemia was demonstrated, as were positive effects on quality of life, satisfac- tion 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 in- sulin dosage is the preferred method to prevent hypoglycemia (86). For un- planned exercise, intake of additional car- bohydrate is usually needed. Moderate- intensity exercise increases glucose utilization by 2–3 mg � kg�1 � min�1

above usual requirements (87). Thus, a 70-kg person would need �10 –15 g ad- ditional carbohydrate per hour of moder- ate intensity physical activity. More carbohydrate is needed for intense activity.

A 2005 American Diabetes Associa- tion statement addresses diabetes MNT for children and adolescents with type 1 diabetes (88).

Nutrition interventions for type 2 diabetes

Recommendations ● Individuals with type 2 diabetes are en-

couraged to implement lifestyle modi- fications that reduce intakes of energy, saturated and trans fatty acids, choles- terol, and sodium and to increase phys- ical activity in an effort to improve glycemia, dyslipidemia, and blood pressure. (E)

● Plasma glucose monitoring can be used to determine whether adjustments in foods and meals will be sufficient to achieve blood glucose goals or if medi- cation(s) needs to be combined with MNT. (E)

Healthy lifestyle nutrition recom- mendations 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 in- take 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 nu- trition priority is to encourage individuals with type 2 diabetes to implement life- style strategies that will improve glyce- mia, dyslipidemia, and blood pressure.

Although there are similarities to those above for type 1 diabetes, MNT recommen- dations for established type 2 diabetes differ in several aspects from both recommen- dations for type 1 diabetes and the pre- vention of diabetes. MNT progresses from prevention of overweight and obesity, to improving insulin resistance and prevent- ing or delaying the onset of diabetes, and to contributing to improved metabolic control in those with diabetes. With es- tablished type 2 diabetes treated with fixed doses of insulin or insulin secreta- gogues, consistency in timing and carbo- hydrate content of meals is important. However, rapid-acting insulins and rap- id-acting insulin secretagogues allow for more flexible food intake and lifestyle as in individuals with type 1 diabetes.

Increased physical activity by individ- uals with type 2 diabetes can lead to im- proved glycemia, decreased insulin resistance, and a reduction in cardiovas- cular risk factors, independent of change in body weight. At least 150 min/week of moderate-intensity aerobic physical ac-

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S68 DIABETES CARE, VOLUME 31, SUPPLEMENT 1, JANUARY 2008

tivity, distributed over at least 3 days and with no more than 2 consecutive days without physical activity is recommended (89). Resistance training is also effective in improving glycemia and, in the absence of proliferative retinopathy, people with type 2 diabetes can be encouraged to per- form resistance exercise three times a week (89).

Nutrition interventions for pregnancy and lactation with diabetes

Recommendations ● Adequate energy intake that provides

appropriate weight gain is recom- mended during pregnancy. Weight loss is not recommended; however, for overweight and obese women with GDM, modest energy and carbohydrate restriction may be appropriate. (E)

● Ketonemia from ketoacidosis or starva- tion ketosis should be avoided. (C)

● MNT for GDM focuses on food choices for appropriate weight gain, normogly- cemia, and absence of ketones. (E)

● Because GDM is a risk factor for subse- quent type 2 diabetes, after delivery, lifestyle modifications aimed at reduc- ing weight and increasing physical ac- tivity are recommended. (A)

Prepregnancy MNT includes an indi- vidualized prenatal meal plan to optimize blood glucose control. During pregnancy, the distribution of energy and carbohy- drate intake should be based on the wom- an’s food and eating habits and plasma glucose responses. 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 glu- cose 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 normo- glycemia, and absence of ketosis. Specific nutrition and food recommendations are determined and subsequently modified based on individual assessment and self- monitoring of blood glucose. All women with GDM should receive MNT at the time of diagnosis. A recent large clinical trial reported that treatment of GDM with nutrition therapy, blood glucose monitor-

ing, and insulin therapy as required for glycemic control reduced serious perina- tal complications without increasing the rate of cesarean delivery as compared with routine care (90). Maternal health– related quality of life was also improved.

Hypocaloric diets in obese women with GDM can result in ketonemia and ketonuria. However, moderate caloric re- striction (reduction by 30% of estimated energy needs) in obese women with GDM may improve glycemic control without ketonemia and reduce maternal weight gain. Insufficient data are available to de- termine how such diets affect perinatal outcomes. Daily food records, weekly weight checks, and ketone testing can be used to determine individual energy re- quirements and whether a woman is un- dereating to avoid insulin therapy.

The amount and distribution of car- bohydrate should be based on clinical outcome measures (hunger, plasma glu- cose levels, weight gain, ketone levels), but a minimum of 175 g carbohydrate/ day should be provided (22). Carbohy- drate 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 acceler- ated 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 glyce- mia. If insulin therapy is added to MNT, maintaining carbohydrate consistency at meals and snacks becomes a primary goal.

Although most women with GDM re- vert to normal glucose tolerance postpar- tum, they are at increased risk of GDM in subsequent pregnancies and type 2 diabe- tes later in life. Lifestyle modifications af- ter pregnancy aimed at reducing weight and increasing physical activity are rec- ommended, as they reduce the risk of subsequent diabetes (26,91). Breast- feeding is recommended for infants of women with preexisting diabetes or GDM; however, successful lactation re- quires planning and coordination of care (92). In most situations, breast-feeding mothers require less insulin because of the calories expended with nursing. Lac- tating women have reported fluctuations in blood glucose related to nursing ses- sions, often requiring a snack containing carbohydrate before or during breast- feeding (92).

Nutrition interventions for older adults with diabetes

Recommendations ● Obese older adults with diabetes may

benefit from modest energy restriction and an increase in physical activity; en- ergy requirement may be less than for a younger individual of a similar weight. (E)

● A daily multivitamin supplement may be appropriate, especially for those older adults with reduced energy in- take. (C)

The American Geriatrics Society em- phasizes the importance of MNT for older adults with diabetes. For obese individu- als, a modest weight loss of 5–10% of body weight may be indicated (93,94). However, an involuntary gain or loss of �10 lb or 10% of body weight in �6 months should be addressed in the MNT evaluation (1,95,96). Physical activity is needed to attenuate loss of lean body mass that can occur with energy restriction. Ex- ercise training can significantly reduce the decline in maximal aerobic capacity that occurs with age, improve risk factors for atherosclerosis, slow the age-related de- cline in lean body mass, decrease central adiposity, and improve insulin sensitivi- ty—all potentially beneficial for the older adult with diabetes (89,97). However, ex- ercise can also pose potential risks such as cardiac ischemia, musculoskeletal inju- ries, and hypoglycemia in patients treated with insulin or insulin secretagogues.

NUTRITION RECOMMENDATIONS FOR CONTROLLING DIABETES COMPLICATIONS (TERTIARY PREVENTION)

Microvascular complications

Recommendations ● Reduction of protein intake to 0.8 –1.0

g � kg body wt�1 � day�1 in individuals with diabetes and the earlier stages of chronic kidney disease (CKD) and to 0.8 g � kg body wt�1 � day�1 in the later stages of CKD may improve measures of renal function (urine albumin excre- tion rate, glomerular filtration rate) and is recommended. (B)

● MNT that favorably affects cardiovas- cular risk factors may also have a favorable effect on microvascular complications such as retinopathy and nephropathy. (C)

Position Statement

DIABETES CARE, VOLUME 31, SUPPLEMENT 1, JANUARY 2008 S69

Progression of diabetes complications may be modified by improving glycemic control, lowering blood pressure, and, potentially, reducing protein intake. Nor- mal protein intake (15–20% of energy) does not appear to be associated with risk of developing diabetic nephropathy (1), but the long-term effect on development of nephropathy of dietary protein intake �20% of energy has not been deter- mined. In several studies of subjects with diabetes and microalbuminuria, urinary albumin excretion rate and decline in glo- merular filtration were favorably influ- enced by reduction of protein intake to 0.8 –1.0 g � kg body wt�1 � day�1 (see PROTEIN IN DIABETES MANAGEMENT section) (98 –101). Although reduction of protein intake to 0.8 g � kg body wt�1 � day�1

was prescribed, subjects who were not able to achieve this level of reduction also showed improvements in renal function (99,100).

In individuals with diabetes and mac- roalbuminuria, reducing protein from all sources to 0.8 g � kg body wt�1 � day�1

has been associated with slowing the de- cline in renal function (1,102); however, such reductions in protein need to main- tain good nutritional status in patients with chronic renal failure (103). Al- though several studies have explored the potential benefit of plant proteins in place of animal proteins and specific animal proteins in diabetic individuals with mi- croalbuninuria, the data are inconclusive (1,104).

Observational data suggest that dys- lipidemia may increase albumin excretion and the rate of progression of diabetic ne- phropathy (105). 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 (106). Whereas these observations do not con- firm that MNT will affect diabetic ne- phropathy, MNT designed to reduce the risk for CVD may have favorable effects on microvascular complications of diabetes.

Treatment and management of CVD risk

Recommendations ● Target A1C is as close to normal as pos-

sible without significant hypoglycemia. (B)

● For patients with diabetes at risk for CVD, diets high in fruits, vegetables, whole grains, and nuts may reduce the risk. (C)

● For patients with diabetes and symp- tomatic heart failure, dietary sodium intake of �2,000 mg/day may reduce symptoms. (C)

● In normotensive and hypertensive indi- viduals, a reduced sodium intake (e.g., 2,300 mg/day) with a diet high in fruits, vegetables, and low-fat dairy products lowers blood pressure. (A)

● In most individuals, a modest amount of weight loss beneficially affects blood pressure. (C)

In the EDIC (Epidemiology of Diabe- tes Interventions and Complications) study, the follow-up of the DCCT (Diabe- tes Control and Complications Trial), in- tensive treatment of type 1 diabetic subjects during the DCCT study period improved glycemic control and signifi- cantly reduced the risk of the combined end point of cardiovascular death, myo- cardial infarction, and stroke (107). Ad- justment for A1C explained most of the treatment effect. The risk reductions ob- tained with improved glycemia exceeded those that have been demonstrated for other interventions such as cholesterol and blood pressure reductions. Observa- tional data from the UKPDS suggest that CVD risk in type 2 diabetes is also pro- portionate to the level of A1C elevation (107a).

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 popu- lation are probably applicable to individ- uals with diabetes. The previous section on dietary fat addresses the need to re- duce intake of saturated and trans fatty acids and cholesterol.

Hypertension, which is predictive of progression of micro- as well as macro- vascular complications of diabetes, can be prevented and managed with interven- tions including weight loss, physical ac- tivity, 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 (7,108,109). The effects of lifestyle interventions on hyper- tension appear to be additive.

Reduction in blood pressure in peo- ple 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 reduc- tions 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. Nutrition recommendations from the American College of Physicians/American Heart Association suggest moderate so- dium restriction (�2,000 mg/day) for pa- tients with structural heart disease or symptomatic heart failure (110). Alcohol intake is discouraged in patients at high risk for heart failure.

NUTRITION INTERVENTIONS FOR ACUTE COMPLICATIONS AND SPECIAL CONSIDERATIONS FOR PATIENTS WITH COMORBIDITIES IN ACUTE AND CHONIC CARE FACILITIES

Hypoglycemia

Recommendations ● Ingestion of 15–20 g glucose is the pre-

ferred treatment for hypoglycemia, al- though any form of carbohydrate that contains glucose may be used. (A)

● The response to treatment of hypogly- cemia should be apparent in 10 –20 min; however, plasma glucose should be tested again in �60 min, as addi- tional treatment may be necessary. (B)

In individuals taking insulin or insu- lin secretagogues, changes in food intake, physical activity, and medication can con- tribute to the development of hypoglyce- mia. Treatment of hypoglycemia (plasma glucose �70 mg/dl) requires ingestion of glucose or glucose-containing foods. The acute glycemic response correlates better with the glucose content than with the carbohydrate content of the food (1). With insulin-induced hypoglycemia, 10 g oral glucose raises plasma glucose levels by �40 mg/dl over 30 min, while 20 g oral glucose raises plasma glucose levels by �60 mg/dl over 45 min. In each case, glucose levels often begin to fall �60 min after glucose ingestion (111).

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S70 DIABETES CARE, VOLUME 31, SUPPLEMENT 1, JANUARY 2008

Table 3—Major nutrition recommendations and interventions

Effectiveness of MNT ● Individuals who have pre-diabetes or diabetes should receive individualized MNT; such therapy is best provided by a registered dietitian familiar with the components of diabetes MNT. (B) ● Nutrition counseling should be sensitive to the personal needs, willingness to change, and ability to make changes of the individual with pre-diabetes or diabetes. (E)

Energy balance, overweight, and obesity ● In overweight and obese insulin-resistant individuals, modest weight loss has been shown to improve insulin resistance. Thus, weight loss is recommended for all such individuals who have or are at risk for diabetes. (A) ● For weight loss, either low-carbohydrate or low-fat calorie-restricted diets may be effective in the short term (up to 1 year). (A) ● For patients on low-carbohydrate diets, monitor lipid profiles, renal function, and protein intake (in those with nephropathy), and adjust hypoglycemic therapy as needed. (E) ● Physical activity and behavior modification are important components of weight loss programs and are most helpful in maintenance of weight loss. (B) ● Weight loss medications may be considered in the treatment of overweight and obese individuals with type 2 diabetes and can help achieve a 5–10% weight loss when combined with lifestyle modification. (B) ● Bariatric surgery may be considered for some individuals with type 2 diabetes and BMI �35 kg/m2 and can result in marked improvements in glycemia. The long-term benefits and risks of bariatric surgery in individuals with pre-diabetes or diabetes continue to be studied. (B)

Preventing diabetes (primary prevention) ● Among individuals at high risk for developing type 2 diabetes, structured programs that emphasize lifestyle changes that include moderate weight loss (7% body weight) and regular physical activity (150 min/week), with dietary strategies including reduced calories and reduced intake of dietary fat, can reduce the risk for developing diabetes and are therefore recommended. (A) ● Individuals at high risk for type 2 diabetes should be encouraged to achieve the USDA recommendation for dietary fiber (14 g fiber/1,000 kcal) and foods containing whole grains (one-half of grain intake). (B) ● 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. (E) ● 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. (B) ● No nutrition recommendation can be made for preventing type 1 diabetes. (E) ● 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. (E)

Controlling diabetes (secondary prevention) Carbohydrate in diabetes management

● A dietary pattern that includes carbohydrate from fruits, vegetables, whole grains, legumes, and low-fat milk is encouraged for good health. (B) ● Monitoring carbohydrate, whether by carbohydrate counting, exchanges, or experienced-based estimation, remains a key strategy in achieving glycemic control. (A) ● The use of glycemic index and load may provide a modest additional benefit over that observed when total carbohydrate is considered alone. (B) ● 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. (A) ● 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. (B) ● Sugar alcohols and nonnutritive sweeteners are safe when consumed within the daily intake levels established by the FDA. (A)

Fat and cholesterol in diabetes management ● Limit saturated fat to �7% of total calories. (A) ● Intake of trans fat should be minimized. (E) ● In individuals with diabetes, lower dietary cholesterol to �200 mg/day. (E) ● 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. (B)

Protein in diabetes management ● For individuals with diabetes and normal renal function, there is insufficient evidence to suggest that usual protein intake (15–20% of energy) should be modified. (E) ● 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. (A)

Continued on following page

Position Statement

DIABETES CARE, VOLUME 31, SUPPLEMENT 1, JANUARY 2008 S71

Table 3—Continued

● High-protein diets are not recommended as a method for weight loss at this time. The long-term effects of protein intake �20% of calories on diabetes management and its complications are unknown. 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. (E)

Alcohol in diabetes management ● 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). (E) ● To reduce risk of nocturnal hypoglycemia in individuals using insulin or insulin secretagogues, alcohol should be consumed with food. (E) ● 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. (B)

Micronutrients in diabetes management ● 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. (A) ● 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. (A) ● Benefit from chromium supplementation in individuals with diabetes or obesity has not been clearly demonstrated and therefore can not be recommended. (E)

Nutrition interventions for type 1 diabetes ● For individuals with type 1 diabetes, insulin therapy should be integrated into an individual’s dietary and physical activity pattern. (E) ● 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. (A) ● 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. (C) ● For planned exercise, insulin doses can be adjusted. For unplanned exercise, extra carbohydrate may be needed. (E)

Nutrition interventions for type 2 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. (E) ● 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. (E)

Nutrition interventions for pregnancy and lactation with diabetes ● 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. (E) ● Ketonemia from ketoacidosis or starvation ketosis should be avoided. (C) ● MNT for GDM focuses on food choices for appropriate weight gain, normoglycemia, and absence of ketones. (E) ● 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. (A)

Nutrition interventions for older adults with diabetes ● 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. (E) ● A daily multivitamin supplement may be appropriate, especially for those older adults with reduced energy intake. (C)

Treating and controlling diabetes complications (tertiary prevention) Microvascular complications

● Reduction of protein intake to 0.8–1.0 g � kg body wt�1 � day�1 in individuals with diabetes and the earlier stages of CKD and to 0.8 g � kg body wt�1 � day�1 in the later stages of CKD may improve measures of renal function (urine albumin excretion rate, glomerular filtration rate) and is recommended. (B) ● MNT that favorably affects cardiovascular risk factors may also have a favorable effect on microvascular complications such as retinopathy and nephropathy. (C)

Treatment and management of CVD risk ● Target A1C is as close to normal as possible without significant hypoglycemia. (B) ● For patients with diabetes at risk for CVD, diets high in fruits, vegetables, whole grains, and nuts may reduce the risk. (C) ● For patients with diabetes and symptomatic heart failure, dietary sodium intake of �2,000 mg/day may reduce symptoms. (C) ● In normotensive and hypertensive individuals, a reduced sodium intake (e.g., 2,300 mg/day) with a diet high in fruits, vegetables, and low-fat dairy products lowers blood pressure. (A) ● In most individuals, a modest amount of weight loss beneficially affects blood pressure. (C)

Continued on following page

Nutrition recommendations and interventions

S72 DIABETES CARE, VOLUME 31, SUPPLEMENT 1, JANUARY 2008

Although pure glucose may be the preferred treatment, any form of carbohy- drate that contains glucose will raise blood glucose (111). Adding protein to carbohydrate does not affect the glycemic response and does not prevent subse- quent hypoglycemia. Adding fat, how- ever, may retard and then prolong the acute glycemic response. During hypo- glycemia, gastric-emptying rates are twice as fast as during euglycemia and are sim- ilar for liquid and solid foods.

Acute illness

Recommendations ● During acute illnesses, insulin and oral

glucose-lowering medications should be continued. (A)

● During acute illnesses, testing of plasma glucose and ketones, drinking adequate amounts of fluids, and ingest- ing carbohydrate are all important. (B)

Acute illnesses can lead to the devel- opment of hyperglycemia and, in individ- uals with type 1 diabetes, ketoacidosis. During acute illnesses, with the usual ac- companying increases in counterregula- tory hormones, the need for insulin and oral glucose-lowering medications con- tinues and often is increased. Testing plasma glucose and ketones, drinking ad- equate amounts of fluid, and ingesting carbohydrate, especially if plasma glucose is �100 mg/dl, are all important during acute illness. In adults, ingestion of 150 –

200 g carbohydrate daily (45–50 g every 3– 4 h) should be sufficient to prevent starvation ketosis (1).

Patients with diabetes in acute health care facilities

Recommendations ● Establishing an interdisciplinary team,

implementation of MNT, and timely di- abetes-specific discharge planning im- proves the care of patients with diabetes during and after hospitalizations. (E)

● Hospitals should consider implement- ing a diabetes meal-planning system that provides consistency in the carbo- hydrate content of specific meals. (E)

Hyperglycemia in hospitalized pa- tients is common and represents an im- portant marker of poor clinical outcome and mortality in both patients with and without diabetes (112). Optimizing glu- cose control in these patients is associated with better outcomes (113). An interdis- ciplinary team is needed to integrate MNT into the overall management plan (114,115). Diabetes nutrition self- management education, although poten- tially 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 (114,115).

There is no single meal planning sys- tem that is ideal for hospitalized patients. However, it is suggested that hospitals

consider implementing a consistent- carbohydrate diabetes meal-planning sys- tem (114,115). 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 (114,115). It is recom- mended that the term “ADA diet” no longer be used, since the ADA no longer endorses a single nutrition prescription or percentages of macronutrients.

Special nutrition issues include liquid diets, surgical diets, catabolic illnesses, and enteral or parenteral nutrition (114,115). Patients requiring clear or full liquid diets should receive �200 g carbo- hydrate/day in equally divided amounts at meal and snack times. Liquids should not be sugar free. Patients require carbo- hydrate and calories, and sugar-free liq- uids do not meet these nutritional needs. For tube feedings, either a standard en- teral formula (50% carbohydrate) or a lower– carbohydrate content formula (33– 40% carbohydrate) may be used. Calorie needs for most patients are in the range of 25–35 kcal/kg every 24 h. Care must be taken not to overfeed patients because this can exacerbate hyperglyce- mia. After surgery, food intake should be initiated as quickly as possible. Progres- sion from clear liquids to full liquids to solid foods should be completed as rap- idly as tolerated.

Table 3—Continued

Hypoglycemia ● Ingestion of 15–20 g glucose is the preferred treatment for hypoglycemia, although any form of carbohydrate that contains glucose may be used. (A) ● The response to treatment of hypoglycemia should be apparent in 10–20 min; however, plasma glucose should be tested again in �60 min, as additional treatment may be necessary. (B)

Acute illness ● During acute illnesses, insulin and oral glucose-lowering medications should be continued. (A) ● During acute illnesses, testing of plasma glucose and ketones, drinking adequate amounts of fluids, and ingesting carbohydrate are all important. (B)

Acute health care facilities ● Establishing an interdisciplinary team, implementation of MNT, and timely diabetes-specific discharge planning improves the care of patients with diabetes during and after hospitalizations. (E) ● Hospitals should consider implementing a diabetes meal-planning system that provides consistency in the carbohydrate content of specific meals. (E)

Long-term care facilities ● The imposition of dietary restrictions on elderly patients with diabetes in long-term care facilities is not warranted. Residents with diabetes should be served a regular menu, with consistency in the amount and timing of carbohydrate. (C) ● An interdisciplinary team approach is necessary to integrate MNT for patients with diabetes into overall management. (E) ● There is no evidence to support prescribing diets such as “no concentrated sweets” or “no sugar added.” (E) ● In the institutionalized elderly, undernutrition is likely and caution should be exercised when prescribing weight loss diets. (B)

Position Statement

DIABETES CARE, VOLUME 31, SUPPLEMENT 1, JANUARY 2008 S73

Patients with diabetes in long-term care facilities

Recommendations ● The imposition of dietary restrictions

on elderly patients with diabetes in long-term care facilities is not war- ranted. Residents with diabetes should be served a regular menu, with consis- tency in the amount and timing of car- bohydrate. (C)

● An interdisciplinary team approach is necessary to integrate MNT for patients with diabetes into overall management. (E)

● There is no evidence to support pre- scribing diets such as “no concentrated sweets” or “no sugar added.” (E)

● In the institutionalized elderly, under- nutrition is likely and caution should be exercised when prescribing weight loss diets. (B)

Although the prevalence of undiag- nosed diabetes in elderly nursing home residents is high, not all of such individ- uals require pharmacologic therapy (115,116). Older residents with diabetes in nursing homes tend to be underweight rather than overweight (114). Low body weight has been associated with greater morbidity and mortality in this popula- tion (114,115). Experience has shown that residents eat better when they are given less restrictive diets (115,116). Spe- cialized diabetic diets do not appear to be superior to standard diets in such settings (117,118). Meal plans such as no concen- trated sweets, no sugar added, low sugar, and liberal diabetic diet also are no longer appropriate. These diets do not reflect current diabetes nutrition recommenda- tions and unnecessarily restrict sucrose. (These types of diets are more likely in long-term care facilities than acute care.) Making medication changes to control glucose, lipids, and blood pressure rather than implementing food restrictions can reduce the risk of iatrogenic malnutrition. The specific nutrition interventions rec- ommended will depend on a variety of factors, including age, life expectancy, co- morbidities, and patient preferences (119).

SUMMARY: NUTRITION RECOMMENDATIONS AND INTERVENTIONS FOR DIABETES — Major nutrition recom- mendations and interventions for diabe- tes are listed in Table 3. Monitoring of metabolic parameters, including glucose,

A1C, lipids, blood pressure, body weight, and renal function is essential to assess the need for changes in therapy and to ensure successful outcomes. Many aspects of MNT require additional research.

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