Goals of Nutrition Therapy That Apply to Adults with Diabetes
- To promote and support healthful eating patterns, emphasizing a variety of nutrient-dense foods in appropriate portion sizes, in order to improve overall health and specifically to:
- Attain individualized glycemic, blood pressure, and lipid goals. General recommended goals from the ADA for these markers are as followsa:
- ▶ A1C <7%.
- ▶ Blood pressure <140/80 mm Hg.
- ▶ LDL cholesterol <100 mg/dL; triglycerides <150 mg/dL; HDL cholesterol
>40 mg/dL for men; HDL cholesterol >50 mg/dL for women.
- Achieve and maintain body weight goals.
- Delay or prevent complications of diabetes.
- To address individual nutrition needs based on personal and cultural preferences, health literacy and numeracy, access to healthful food choices, willingness and ability to make behavioral changes, as well as barriers to change.
- To maintain the pleasure of eating by providing positive messages about food choices while limiting food choices only when indicated by scientific evidence.
- To provide the individual with diabetes with practical tools for day-to-day meal planning rather than focusing on individual macronutrients, micronutrients, or single foods.
aA1C, blood pressure, and cholesterol goals may need to be adjusted for the individual based on age, duration of diabetes, health history, and other present health conditions. Further recommendations for individualization of goals can be found in the ADA Standards of Medical Care in Diabetes (http://care.diabetesjournals.org/content/36/Supplement_1/S11.full.pdf html).
Table 1. Nutrition Therapy Recommendations
Topic and Recommendation
- Effectiveness of nutrition therapy
- Nutrition therapy is recommended for all people with type 1 and type 2 diabetes as an effective component of the overall treatment plan. (A)
- Individuals who have diabetes should receive individualized MNT as needed to achieve treatment goals, preferably provided by an RD familiar with the components of diabetes MNT. (A)
- For individuals with type 1 diabetes, participation in an intensive flexible insulin therapy education program using the carbohydrate counting meal planning approach can result in improved glycemic control. (A)
- For individuals using ﬁxed daily insulin doses, consistent carbohydrate intake with respect to time and amount can result in improved glycemic control and reduce risk for hypoglycemia. (B)
- A simple diabetes meal planning approach such as portion control or healthful food choices may be better suited to individuals with type 2 diabetes identiﬁed with health and numeracy literacy concerns. This may also be an effective meal planning strategy for older adults. (C)
- People with diabetes should receive DSME according to national standards and diabetes self-management support when their diabetes is diagnosed and as needed thereafter. (B)
- Because diabetes nutrition therapy can result in cost savings (B) and improved outcomes such as reduction in A1C(A), nutrition therapy should be adequately reimbursed by insurance and other payers. (E)
- Energy balance
- For overweight or obese adults with type 2 diabetes, reducing energy intake while maintaining a healthful eating pattern is recommended to promote weight loss. (A)
- Modest weight loss may provide clinical beneﬁts (improved glycemia, blood pressure, and/or lipids) in some individuals with diabetes, especially those early in the disease process. To achieve modest weight loss, intensive lifestyle interventions (counseling about nutrition therapy, physical activity, and behavior change) with ongoing support are recommended. (A)
- Optimal mix of macronutrients
- Evidence suggests that there is not an ideal percentage of calories from carbohydrate, protein, and fat for all people with diabetes (B). Therefore, macronutrient distribution should be based on individualized assessment of current eating patterns, preferences, and metabolic goals. (E)
- Eating patterns
- A variety of eating patterns (combinations of different foods or food groups) are acceptable for the management of diabetes. Personal preferences (e.g., tradition, culture, religion, health beliefs and goals, economics) and metabolic goals should be considered when recommending one eating pattern over another. (E)
- Evidence is inconclusive for an ideal amount of carbohydrate intake for people with diabetes. Therefore, collaborative goals should be developed with the individual with diabetes. (C)
- The amount of carbohydrates and available insulin may be the most important factor inﬂuencing glycemic response after eating and should be considered when developing the eating plan. (A)
- Monitoring carbohydrate intake, whether by carbohydrate counting or experience-based estimation, remains a key strategy in achieving glycemic control. (B)
- For good health, carbohydrate intake from vegetables, fruits, whole grains, legumes, and dairy products should be advised over intake from other carbohydrate sources, especially those that contain added fats, sugars, or sodium. (B)
- Glycemic index and glycemic load
- Substituting low-glycemic load foods for higher-glycemic load foods may modestly improve glycemic control. (C)
- Dietary ﬁber and whole grains
- People with diabetes should consume at least the amount of ﬁber and whole grains recommended for the general public. (C)
- Substitution of sucrose for starch
- While substituting sucrose-containing foods for isocaloric amounts of other carbohydrates may have similar blood glucose effects, consumption should be minimized to avoid displacing nutrient-dense food choices. (A)
- Fructose consumed as “free fructose” (i.e., naturally occurring in foods such as fruit) may result in better glycemic control compared with isocaloric intake of sucrose or starch (B), and free fructose is not likely to have detrimental effects on triglycerides as long as intake is not excessive (>12% energy). (C)
- People with diabetes should limit or avoid intake of SSBs (from any caloric sweetener including high fructose corn syrup and sucrose) to reduce risk for weight gain and worsening of cardiometabolic risk proﬁle. (B)
- NNSs and hypocaloric sweeteners
- Use of NNSs has the potential to reduce overall calorie and carbohydrate intake if substituted for caloric sweeteners without compensation by intake of additional calories from other food sources. (B)
- For people with diabetes and no evidence of diabetic kidney disease, evidence is inconclusive to recommend an ideal amount of protein intake for optimizing glycemic control or improving one or more CVD risk measures. Therefore, goals should be individualized. (C)
- For people with diabetes and diabetic kidney disease (either micro- or macroalbuminuria), reducing the amount of dietary protein below usual intake is not recommended because it does not alter glycemic measures, cardiovascular risk measures, or the course of GFR decline. (A)
- In individuals with type 2 diabetes, ingested protein appears to increase insulin response without increasing plasma glucose concentrations. Therefore, carbohydrate sources high in protein should not be used to treat or prevent hypoglycemia. (B)
- Total fat
- Evidence is inconclusive for an ideal amount of total fat intake for people with diabetes. Therefore, goals should be individualized (C). Fat quality appears to be far more important than quantity. (B)
- In people with type 2 diabetes, a Mediterranean-style, MUFA-rich eating pattern may beneﬁt glycemic control and CVD risk factors and can therefore be recommended as an effective alternative to a lower-fat, higher-carbohydrate eating pattern. (B)
- Evidence does not support recommending omega-3 (EPA and DHA) supplements for people with diabetes for the prevention or treatment of cardiovascular events. (A)
- As recommended for the general public, an increase in foods containing long-chain omega-3 fatty acids (EPA and DHA) (from fatty ﬁsh) and omega-3 linolenic acid (ALA) is recommended for individuals with diabetes because of their beneﬁcial effects on lipoproteins, prevention of heart disease, and associations with positive health outcomes in observational studies. (B)
- The recommendation for the general public to eat ﬁsh (particularly fatty ﬁsh) at least two times (two servings) per week is also appropriate for people with diabetes. (B)
- Saturated fat, dietary cholesterol, and trans fat
- The amount of dietary saturated fat, cholesterol, and trans fat recommended for people with diabetes is the same as that recommended for the general population. (C)
- Plant stanols and sterols
- Individuals with diabetes and dyslipidemia may be able to modestly reduce total and LDL cholesterol by consuming 1.6-3 g/day of plant stanols or sterols typically found in enriched foods. (C)
- Micronutrients and herbal supplements
- There is no clear evidence of beneﬁt from vitamin or mineral supplementation in people with diabetes who do not have underlying deﬁciencies. (C)
- 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)
- There is insufﬁcient evidence to support the routine use of micronutrients such as chromium, magnesium, and vitamin D to improve glycemic control in people with diabetes. (C)
- There is insufﬁcient evidence to support the use of cinnamon or other herbs/supplements for the treatment of diabetes. (C)
- It is recommended that individualized meal planning include optimization of food choices to meet recommended dietary allowance/dietary reference intake for all micronutrients. (E)
- If adults with diabetes choose to drink alcohol, they should be advised to do so in moderation (one drink per day or less for adult women and two drinks per day or less for adult men). (E)
- Alcohol consumption may place people with diabetes at increased risk for delayed hypoglycemia, especially if taking insulin or insulin secretagogues. Education and awareness regarding the recognition and management of delayed hypoglycemia is warranted. (C)
- The recommendation for the general population to reduce sodium to less than 2,300 mg/day is also appropriate for people with diabetes. (B)
- For individuals with both diabetes and hypertension, further reduction in sodium intake should be individualized. (B)
Table 2. Academy of Nutrition and Dietetics Evidence-Based Nutrition Practice Guidelines
- A series of 3-4 encounters with an RD lasting from 45-90 min.
- The series of encounters should begin at diagnosis of diabetes or at ﬁrst referral to an RD for MNT for diabetes and should be completed within 3-6 months.
- The RD should determine whether additional MNT encounters are needed.
- At least one follow-up encounter is recommended annually to reinforce lifestyle changes and to evaluate and monitor outcomes that indicate the need for changes in MNT or medication(s). An RD should determine whether additional MNT encounters are needed.