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Long-term reduction of adiposity is difficult for most people to achieve, and even harder for individuals with diabetes to achieve given the impact of some medications used to improve glycemic control e. Proteins are structural materials in much of the animal body e. ALA helps your cells' ability to turn sugar into energy and decreases the need for your body to make insulin. Secondary and tertiary prevention interventions include MNT for individuals with diabetes and seek to prevent secondary or control tertiary complications of diabetes. Obes Surg ;
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During pregnancy high blood glucose substantially increases the risk to health for both mother and child as well as the risk of diabetes for the child in the future. Almost half of women who die in low-income countries due to high blood glucose die prematurely, before the age of 70 years. The first WHO Global report on diabetes demonstrates that the number of adults living with diabetes has almost quadrupled since to million adults.
Factors driving this dramatic rise, which is largely on account of type 2 diabetes, include overweight and obesity. The new report calls upon governments to ensure that people are able to make healthy choices and that health systems are able to diagnose, treat and care for people with diabetes. The main goals of the World Health Day campaign are to increase awareness about the rise in diabetes, and its staggering burden and consequences, in particular in low- and middle-income countries; and to trigger a set of specific, effective and affordable actions to tackle diabetes.
Diabetes is a chronic, metabolic disease characterized by elevated levels of blood glucose or blood sugar , which leads over time to serious damage to the heart, blood vessels, eyes, kidneys, and nerves.
The most common is type 2 diabetes, usually in adults, which occurs when the body becomes resistant to insulin or doesn't make enough insulin. In the past three decades the prevalence of type 2 diabetes has risen dramatically in countries of all income levels. Type 1 diabetes, once known as juvenile diabetes or insulin-dependent diabetes, is a chronic condition in which the pancreas produces little or no insulin by itself.
For people living with diabetes, access to affordable treatment, including insulin, is critical to their survival. There is a globally agreed target to halt the rise in diabetes and obesity by The mission of the WHO Diabetes Programme is to prevent type 2 diabetes and to minimize complications and maximize quality of life for all people with diabetes. Research has also compared the benefits of whole grains to fiber. The Dietary Guidelines for Americans, defines whole grains as foods containing the entire grain seed kernel , bran, germ, and endosperm A systematic review 88 concluded that the consumption of whole grains was not associated with improvements in glycemic control in individuals with type 2 diabetes; however, it may have other benefits, such as reductions in systemic inflammation.
As with the general population, individuals with diabetes should consume at least half of all grains as whole grains Resistant starch is defined as starch physically enclosed within intact cell structures as in some legumes, starch granules as in raw potato, and retrograde amylose from plants modified by plant breeding to increase amylose content. It has been proposed that foods containing resistant starch or high amylose foods such as specially formulated cornstarch may modify postprandial glycemic response, prevent hypoglycemia, and reduce hyperglycemia.
However, there are no published long-term studies in subjects with diabetes to prove benefit from the use of resistant starch. Fructans are an indigestible type of fiber that has been hypothesized to have a glucose-lowering effect. Inulin is a fructan commonly added to many processed food products in the form of chicory root.
Limited research in people with diabetes is available. One systematic review that included three short-term studies in people with diabetes showed mixed results of fructan intake on glycemia. There are no published long-term studies in subjects with diabetes to prove benefit from the use of fructans 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.
Sucrose is a disaccharide made of glucose and fructose. Commonly known as table sugar or white sugar, it is found naturally in sugar cane and in sugar beets. However, because foods high in sucrose are generally high in calories, substitution should be made in the context of an overall healthful eating pattern with caution not to increase caloric intake.
Additionally, as with all people, selection of foods containing sucrose or starch should emphasize more nutrient-dense foods for an overall healthful eating pattern People with diabetes should limit or avoid intake of sugar-sweetened beverages SSBs from any caloric sweetener including high-fructose corn syrup and sucrose to reduce risk for weight gain and worsening of cardiometabolic risk profile.
Fructose is a monosaccharide found naturally in fruits. It is also a component of added sugars found in sweetened beverages and processed snacks.
Many foods marketed to people with diabetes may contain large amounts of fructose such as agave nectar ; these foods should not be consumed in large amounts to avoid excess caloric intake and to avoid excessive fructose intake. In terms of glycemic control, Cozma et al. Based on 18 trials, the authors found that isocaloric exchange of fructose for carbohydrates reduced glycated blood proteins and did not significantly affect fasting glucose or insulin.
However, it was noted that applicability may be limited because most of the trials were less than 12 weeks in duration.
With regard to the treatment of hypoglycemia, in a small study comparing glucose, sucrose, or fructose, Husband et al. Therefore, sucrose or glucose in the form of tablets, liquid, or gel may be the preferred treatment over fruit juice, although availability and convenience should be considered. There is now abundant evidence from studies of individuals without diabetes that because of their high amounts of rapidly absorbable carbohydrates such as sucrose or high-fructose corn syrup , large quantities of SSBs should be avoided to reduce the risk for weight gain and worsening of cardiometabolic risk factors — Evidence suggests that consuming high levels of fructose-containing beverages may have particularly adverse effects on selective deposition of ectopic and visceral fat, lipid metabolism, blood pressure, insulin sensitivity, and de novo lipogenesis, compared with glucose-sweetened beverages In terms of specific effects of fructose, concern has been raised regarding elevations in serum triglycerides , Such studies are not available among individuals with diabetes; however, there is little reason to suspect that the diabetic state would mitigate the adverse effects of SSBs.
Use of nonnutritive sweeteners 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. Food and Drug Administration has reviewed several types of hypo-caloric sweeteners e. Research supports that NNSs do not produce a glycemic effect; however, foods containing NNSs may affect glycemia based on other ingredients in the product An American Heart Association and ADA scientific statement on NNS consumption concludes that there is not enough evidence to determine whether NNS use actually leads to reduction in body weight or reduction in cardiometabolic risk factors These conclusions are consistent with a systematic review of hypocaloric sweeteners including sugar alcohols that found little evidence that the use of NNSs lead to reductions in body weight If NNSs are used to replace caloric sweeteners, without caloric compensation, then NNSs may be useful in reducing caloric and carbohydrate intake , although further research is needed to confirm these results 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.
For people with diabetes and diabetic kidney disease either micro- or macroalbuminuria , reducing the amount of dietary protein below the usual intake is not recommended because it does not alter glycemic measures, cardiovascular risk measures, or the course of glomerular filtration rate GFR decline. 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.
One study demonstrated decreased A1C with a higher-protein diet However, other studies showed no effect on glycemic control — However, two trials reported no improvement in CVD risk factors , Factors affecting interpretation of this research include small sample sizes , and study durations of less than 6 months — Several RCTs comparing protein levels in individuals with diabetic kidney disease with either micro- or macroalbuminuria had adequately large sample sizes and durations for interpretation.
Two meta-analyses found no clear benefits on renal parameters from low-protein diets , One factor affecting interpretation of these studies was that actual protein intake differed from goal protein intake.
Two studies reported higher actual protein intake in the lower protein group than in the control groups. None of the five reviewed studies since demonstrated malnourishment as evidenced by hypoalbuminemia with low-protein diets, but both meta-analyses found evidence for this in earlier studies. There is very limited research in people with diabetes and without kidney disease on the impact of the type of protein consumed.
One study did not find a significant difference in glycemic or lipid measures when comparing a chicken- or red meat—based diet For individuals with diabetic kidney disease and macroalbuminuria, changing the source of protein to be more soy-based may improve CVD risk factors but does not appear to alter proteinuria , For individuals with type 2 diabetes, protein does not appear to have a significant effect on blood glucose level , but does appear to increase insulin response , , For this reason, it is not advised to use protein to treat hypoglycemia or to prevent hypo-glycemia.
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. Currently, insufficient data exist to determine a defined level of total energy intake from fat at which risk of inadequacy or prevention of chronic disease occurs, so there is no adequate intake or recommended daily allowance for total fat These recommendations are not diabetes-specific; however, limited research exists in individuals with diabetes.
Fatty acids are categorized as being saturated or unsaturated monounsaturated or polyunsaturated. Trans fatty acids may be unsaturated, but they are structurally different and have negative health effects The type of fatty acids consumed is more important than total fat in the diet in terms of supporting metabolic goals and influencing the risk of CVD 83 , , ; thus more attention should be given to the type of fat intake when individualizing goals.
Individuals with diabetes should be encouraged to moderate their fat intakes to be consistent with their goals to lose or maintain weight. In people with type 2 diabetes, a Mediterranean-style, monounsaturated fatty acid 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.
Evidence from large prospective cohort studies, clinical trials, and a systematic review of RCTs indicate that high-MUFA diets are associated with improved glycemic control and improved CVD risk or risk factors 70 , — The intake of MUFA-rich foods as a component of the Mediterranean-style eating pattern has been studied extensively over the last decade.
However, some of the studies also included caloric restriction, which may have contributed to improvements in glycemic control or blood lipids , In , the Evidence Analysis Library EAL of the Academy of Nutrition and Dietetics found strong evidence that dietary MUFAs are associated with improvements in blood lipids based on 13 studies including participants with and without diabetes.
There is limited evidence in people with diabetes on the effects of omega-6 polyunsaturated fatty acids PUFAs. Controversy exists on the best ratio of omega-6 to omega-3 fatty acids; PUFAs and MUFAs are recommended substitutes for saturated or trans fat , Evidence does not support recommending omega-3 EPA and DHA supplements for people with diabetes for the prevention or treatment of cardiovascular events.
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. 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.
The ADA systematic review identified seven RCTs and one single-arm study — using omega-3 fatty acid supplements and one cohort study on whole-food omega-3 intake. In individuals with type 2 diabetes 88 , supplementation with omega-3 fatty acids did not improve glycemic control, but higher-dose supplementation decreased triglycerides.
Additional blood-derived markers of CVD risk were not consistently altered in these trials. Three longer-duration studies 4 months ; 40 months ; 6. Two studies reported no beneficial effects of supplementation , No differences on estimated year CVD risks were observed with the addition of omega-3 fatty acid supplements compared with placebo Thus, RCTs do not support recommending omega-3 supplements for primary or secondary prevention of CVD despite the strength of evidence from observational and preclinical studies.
Previous studies using supplements had shown mixed effects on fasting blood glucose and A1C levels. However, a study comparing diets with a high proportion of omega-3 fatty fish versus omega-6 lean fish and fat-containing linoleic acid fatty acids reported both diets had no detrimental effect on glucose measures, and both diets improved insulin sensitivity and lipoprotein profiles 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.
Few research studies have explored the relationship between the amount of SFA in the diet and glycemic control and CVD risk in people with diabetes. A systematic review by Wheeler et al. In addition, there is limited research regarding optimal dietary cholesterol and trans fat intake in people with diabetes.
Due to the lack of research in this area, people with diabetes should follow the guidelines for the general population. Consumers can meet this guideline by replacing foods high in SFA i. CVD is a common cause of death among individuals with diabetes.
As a result, individuals with diabetes are encouraged to follow nutrition recommendations similar to the general population to manage CVD risk factors. Individuals with diabetes and dyslipi-demia may be able to modestly reduce total and LDL cholesterol by consuming 1. Plant sterol and stanol esters block the intestinal absorption of dietary and biliary cholesterol 3. Currently, the EAL from the Academy of Nutrition and Dietetics recommends individuals with dyslipidemia incorporate 2—3 g of plant sterol and stanol esters per day as part of a cardioprotective diet through consumption of plant sterol and stanol ester-enriched foods This recommendation, though not specific to people with diabetes, is based on a review of 20 clinical trials These studies used doses of 1.
Two of these studies were in people with type 1 diabetes , , and one found an added benefit to cholesterol reduction in those who were already on statin treatment In addition, two RCTs compared the efficacy of plant sterol consumption 1. Neither study found a difference in lipid profiles between the two groups, suggesting that efficacy of this treatment is similar for those with and without diabetes who are hypercholesterolemic , A wide range of foods and beverages are now available that contain plant sterols including many spreads, dairy products, grain and bread products, and yogurt.
These products can contribute a considerable amount of calories. If used, patients should substitute them for comparable foods they eat in order to keep calories balanced and avoid weight gain 3 , There is no clear evidence of benefit from vitamin or mineral supplementation in people with diabetes who do not have underlying deficiencies.
Routine supplementation with antioxidants, such as vitamins E and C and carotene, is not advised because of lack of evidence of efficacy and concern related to long-term safety. There is insufficient evidence to support the routine use of micro-nutrients such as chromium, magnesium, and vitamin D to improve glycemic control in people with diabetes.
There currently exists insufficient evidence of benefit from vitamin or mineral supplementation in people with or without diabetes in the absence of an underlying deficiency 3 , , Because uncontrolled diabetes is often associated with micronutrient deficiencies , people with diabetes should be aware of the importance of acquiring daily vitamin and mineral requirements from natural food sources and a balanced diet 3.
For select groups of individuals such as the elderly, pregnant or lactating women, vegetarians, and those on calorie-restricted diets, a multivitamin supplement may be necessary While there has been significant interest in antioxidant supplementation as a treatment for diabetes, current evidence not only demonstrates a lack of benefit with respect to glycemic control and progression of complications, but also provides evidence of potential harm of vitamin E, carotene, and other antioxidant supplements — A systematic review on the effect of chromium supplementation on glucose metabolism and lipids concluded that larger effects were more commonly observed in poor-quality studies and that evidence is limited by poor study quality and heterogeneity in methodology and results Evidence from clinical studies evaluating magnesium , and vitamin D — supplementation to improve glycemic control in people with diabetes is likewise conflicting.
A systematic review evaluating the effects of cinnamon in people with diabetes concluded there is currently insufficient evidence to support its use, and there is a lack of compelling evidence for the use of other herbal products for the improvement of glycemic control in people with diabetes It is important to consider that herbal products are not standardized and vary in the content of active ingredients and may have the potential to interact with other medications 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.
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. Moderate alcohol intake may also convey cardiovascular risk reduction and mortality benefits in people with diabetes — , with the type of alcohol consumed not influencing these beneficial effects , Accordingly, the recommendations for alcohol consumption for people with diabetes are the same as for the general population.
Adults with diabetes choosing to consume alcohol should limit their intake to one serving or less per day for women and two servings or less per day for men One alcohol-containing beverage is defined as 12 oz beer, 5 oz wine, or 1. Abstention from alcohol should be advised, however, for people with a history of alcohol abuse or dependence, women during pregnancy, and people with medical conditions such as liver disease, pancreatitis, advanced neuropathy, or severe hypertriglyceridemia 3.
Despite the potential glycemic and cardiovascular benefits of moderate alcohol consumption, use may place people with diabetes at increased risk for delayed hypoglycemia. This is particularly true in those using insulin or insulin secretagogue therapies.
Consuming alcohol with food can minimize the risk of nocturnal hypoglycemia 3 , — Individuals with diabetes should receive education regarding the recognition and management of delayed hypoglycemia and the potential need for more frequent self-monitoring of blood glucose after consuming alcoholic beverages.
For individuals with both diabetes and hypertension, further reduction in sodium intake should be individualized. Limited studies have been published on sodium reduction in people with diabetes.
A Cochrane review of RCTs found that decreasing sodium intake reduces blood pressure in those with diabetes Likewise, a small study in people with type 2 diabetes showed that following the DASH diet and reducing sodium intake to about 2, mg led to improvements in blood pressure and other measures on cardiovascular risk factors Incrementally lower sodium intakes i.
Additionally, an IOM report suggests there is no evidence on health outcomes to treat certain population subgroups—which includes individuals with diabetes—differently than the general U. When individualizing sodium intake recommendations, consideration must also be given to issues such as the palatability, availability, and additional cost of specialty low sodium products and the difficulty in achieving both low sodium recommendations and a nutritionally adequate diet given these limitations The food industry can play a major role in lowering sodium content of foods to help people meet sodium recommendations , A wide range of diabetes meal planning approaches or eating patterns have been shown to be clinically effective, with many including a reduced energy intake component.
There is not one ideal percentage of calories from carbohydrates, protein, or fat that is optimal for all people with diabetes. If the individual would like to try a different eating pattern, this should also be supported by the health care team.
Various behavior change theories and strategies can be used to tailor nutrition interventions to help the client achieve specific health and quality-of-life outcomes Multiple meal planning approaches and eating patterns can be effective for achieving metabolic goals.
This may need to be adjusted over time based on changes in life circumstances, preferences, and disease course. A summary of key topics for nutrition education can be found in Table 4. The evidence presented in this position statement concurs with the review previously published by Wheeler et al.
Evaluating nutrition evidence is complex given that multiple dietary factors influence glycemic control and CVD risk factors, and the influence of a combination of factors can be substantial. Based on a review of the evidence, it is clear that gaps in the literature continue to exist and further research on nutrition and eating patterns is needed in individuals with type 1 and type 2 diabetes.
The basis for the beneficial effects of the Mediterranean-style eating pattern and approaches to translation of the Mediterranean-style eating pattern into diverse populations. The development of standardized definitions for high— and low—glycemic index diets and implementation of these definitions in long-term studies to further evaluate their impact on glycemic control.
The development of standardized definitions for low- to moderate-carbohydrate diets and determining long-term sustainability. Whether NNSs, when used to replace caloric sweeteners, are useful in reducing caloric and carbohydrate intake. The impact of key nutrients on cardiovascular risk, such as saturated fat, cholesterol, and sodium in individuals with both type 1 and type 2 diabetes.
Importantly, research needs to move away from just evaluating the impact of individual nutrients on glycemic control and cardiovascular risk. More research on eating patterns, unrestricted and restricted energy diets, and diverse populations is needed to evaluate their long-term health benefits in individuals with diabetes. Individuals eat nutrients from foods and within the context of mixed meals, and nutrient intakes are intercorrelated, so overall eating patterns must be studied to fully understand how these eating patterns impact glycemic control 88 , Eating patterns are selected by individuals based on more than the healthfulness of food and food availability; tradition, cultural food systems, health beliefs, and economics are also important Studies on gene-diet interactions will also be important, as well as studies on potential epigenetic effects that depend on nutrients to moderate gene expression.
Given the benefits of both nutrition therapy and MNT for individuals with diabetes, it is also important to study systematic processes within the context of health care delivery that encourage more individuals with diabetes to receive nutrition therapy initially, upon diagnosis, and long term.
Further research is also needed on the best tools and strategies for educating individuals with diabetes e. This research should include multiple settings that can impact food choices for individuals with diabetes, such as where they live, work, learn, and play. Individuals with diabetes spend the majority of their time outside health care settings so more research on how public health, the health care system, and the community can support individuals with diabetes in their efforts to achieve healthful eating is needed.
There is no standard meal plan or eating pattern that works universally for all people with diabetes 1. Nutrition interventions should emphasize a variety of minimally processed nutrient-dense foods in appropriate portion sizes as part of a healthful eating pattern and provide the individual with diabetes with practical tools for day-to-day food plan and behavior change that can be maintained over the long term.
This position statement was written at the request of the ADA Executive Committee, which has approved the final document. The process involved extensive literature review, one face-to-face meeting of the entire writing group, one subgroup writing meeting, numerous teleconferences, and multiple revisions via e-mail communications.
The authors are indebted to Sue Kirkman, MD, for her guidance and support during this process. The two face-to-face meetings and the travel of the writing group and teleconference calls were supported by the ADA. The authors also gratefully acknowledge the following experts who provided critical review of a draft of this statement: During the past 12 months, the following relationships with companies whose products or services directly relate to the subject matter in this document are declared: No other potential conflicts of interest relevant to this article were reported.
All the named writing group authors contributed substantially to the document including researching data, contributing to discussions, writing and reviewing text, and editing the manuscript.
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Table 1 Nutrition therapy recommendations. Achieve and maintain body weight goals. Delay or prevent complications of diabetes. Diabetes nutrition therapy Ideally, the individual with diabetes should be referred to a registered dietitian RD or a similarly credentialed nutrition professional if outside of the U. View inline View popup Download powerpoint. Effectiveness of Nutrition Therapy Nutrition therapy is recommended for all people with type 1 and type 2 diabetes as an effective component of the over all 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 the 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. 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 The common coexistence of hyperlipidemia and hypertension in people with diabetes requires monitoring of metabolic parameters 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 More than three out of every four adults with diabetes are at least overweight 17 , and nearly half of individuals with diabetes are obese 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 Although numerous studies have attempted to identify the optimal mix of macronutrients for the meal plans of people with diabetes, a systematic review 88 found that there is no ideal mix that applies broadly and that macronutrient proportions should be individualized. Eating Patterns A variety of eating patterns combinations of different foods or food groups are acceptable for the management of diabetes. E Eating patterns, also called dietary patterns, is a term used to describe combinations of different foods or food groups that characterize relationships between nutrition and health promotion and disease prevention Table 3 Reviewed eating patterns.
Individual macronutrients Carbohydrates Evidence is inconclusive for an ideal amount of carbohydrate intake for people 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 Evidence is insufficient to support one specific amount of carbohydrate intake for all people with diabetes.
Quality of carbohydrates Glycemic Index and Glycemic Load Substituting low—glycemic load foods for higher—glycemic load foods may modestly improve glycemic control. C The ADA recognizes that education about glycemic index and glycemic load occurs during the development of individualized eating plans for people with diabetes.
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 Intake of dietary fiber is associated with lower all-cause mortality , in people with diabetes. Resistant starch and fructans Resistant starch is defined as starch physically enclosed within intact cell structures as in some legumes, starch granules as in raw potato, and retrograde amylose from plants modified by plant breeding to increase amylose content.
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 Sucrose is a disaccharide made of glucose and fructose. C People with diabetes should limit or avoid intake of sugar-sweetened beverages 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 Fructose is a monosaccharide found naturally in fruits. Nonnutritive Sweeteners and Hypocaloric Sweeteners Use of nonnutritive sweeteners 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.
Protein 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 the usual intake is not recommended because it does not alter glycemic measures, cardiovascular risk measures, or the course of glomerular filtration rate GFR decline. A In individuals with type 2 diabetes, ingested protein appears to increase insulin response without increasing plasma glucose concentrations.
Total Fat Evidence is inconclusive for an ideal amount of total fat intake for people with diabetes; therefore, goals should be individualized. B Currently, insufficient data exist to determine a defined level of total energy intake from fat at which risk of inadequacy or prevention of chronic disease occurs, so there is no adequate intake or recommended daily allowance for total fat B Evidence from large prospective cohort studies, clinical trials, and a systematic review of RCTs indicate that high-MUFA diets are associated with improved glycemic control and improved CVD risk or risk factors 70 , — Omega-3 Fatty Acids 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 The ADA systematic review identified seven RCTs and one single-arm study — using omega-3 fatty acid supplements and one cohort study on whole-food omega-3 intake. 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 Few research studies have explored the relationship between the amount of SFA in the diet and glycemic control and CVD risk in people with diabetes. Plant Stanols and Sterols Individuals with diabetes and dyslipi-demia may be able to modestly reduce total and LDL cholesterol by consuming 1.
C Plant sterol and stanol esters block the intestinal absorption of dietary and biliary cholesterol 3. 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 micro-nutrients such as chromium, magnesium, and vitamin D to improve glycemic control in people with diabetes. E There currently exists insufficient evidence of benefit from vitamin or mineral supplementation in people with or without diabetes in the absence of an underlying deficiency 3 , , Alcohol 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. B For individuals with both diabetes and hypertension, further reduction in sodium intake should be individualized. B Limited studies have been published on sodium reduction in people with diabetes.
Clinical priorities for nutrition management for all people with diabetes A wide range of diabetes meal planning approaches or eating patterns have been shown to be clinically effective, with many including a reduced energy intake component.
Table 4 Summary of priority topics. Future research directions The evidence presented in this position statement concurs with the review previously published by Wheeler et al. For example, future studies should address: The relationships between eating patterns and disease in diverse populations. Intake of SFA and its relationship to insulin resistance.
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