Diabetic Nutrition Therapy

Medical nutrition therapy is an integral component of diabetes management and diabetes self management education for both the type 1 and type 2 diabetic. It involves conducting a nutrition assessment to evaluate the diabetic's food intake, metabolic status, lifestyle, and willingness to make changes; goal setting; nutrition education; and evaluation. To enhance compliance the medical nutrition therapy plan should be individualized and take into consideration the diabetics lifestyle, cultural background, and financial situation.

The American Diabetes Association's recommendations for diabetic nutritional therapy are outlined below.

Carbohydrates:

• Terms such as simple sugars, complex carbohydrates, and fast acting carbohydrates are not well-defined and use of these terms should be avoided. The preferred terms are sugars, starch, and fiber.
• Foods containing carbohydrates from whole grains, fruits, vegetables, and low fat milk should be included in a healthy diet.
• Total amount of carbohydrates in meals or snacks is more important than source or type.
• Sucrose does not increase glycemia to a greater than isocaloric amounts of starch. Sucrose and sucrose containing foods do not need to be restricted, but if used, should be substituted for other carbohydrate sources.
• Nonnutritive sweeteners are safe when consumed within acceptable daily intake levels established by the Food and Drug Administration.
• Individuals using intensive insulin therapy should adjust their before-meal insulin doses based on carbohydrate content of meals.
• As with the general public, consumption of dietary fiber should be encouraged.
• Individuals using daily insulin injections should be consistent in day-to-day carbohydrate intake.

Proteins:

• Although protein stimulates insulin secretion as potentially as a carbohydrate, ingested protein does not increase plasma glucose levels in controlled type 2 diabetes.
• For diabetics not in optimal glucose control, protein needs may be greater (but not greater than usual intake) then the recommended dietary allowances (RDA).
• Protein intake of 15% to 20% of total daily energy does not need to be modified if renal function is normal.
• Long term effects of high protein, low carbohydrate diets are unknown. Although they generate short term weight loss and improved glucose levels, there is no evidence that weight loss is maintained.

Dietary Fats:

• Less than 10% of energy intake should come from saturated fats.
• Dietary cholesterol intake should be less than 300 mg/day.
• To lower low-density lipoprotein (LDL) cholesterol, saturated fat intake can be reduced if weight loss is desired. If weight loss is not a goal, saturated fat can be replaced with either carbohydrate or monounsaturated fat.
• Intake of trans-unsaturated fatty acids should be minimized.
• Reduced fat diets contribute to modest weight loss and improvement of dyslipidemia when maintained.
• Polyunsaturated fat intake should be approximately 10% of total energy intake.

Energy Balance and Obesity:

• In insulin resistant diabetics, reduced energy intake and modest weight loss improve short term insulin resistance and glucose control.
• Long term weight loss is best facilitated by structured programs that emphasize lifestyle changes that include education, reduced fat (<30% total kcalories) and energy intake, regular physical activity, and regular personal contact.
• Exercise and behavior modification are most useful as adjuncts to other weight loss strategies.
• Standard weight reduction diets, when used alone, are unlikely to produce long term weight loss.

Micronutrients:

• There is no benefit from vitamin or mineral supplementation when there are no underlying deficiencies. Exceptions include folate for prevention of birth defects and calcium for the prevention of osteoporosis.
• Routine supplementation of the diet with antioxidants is not advised because of uncertainties related to long term efficacy and safety.

Alcohol:

• If diabetics choose to drink alcohol, daily intake should be limited to two drinks for men and one drink for women. One drink is defined and 12 oz of beer, 5 oz of wine, or 1.5 oz of hard liquor.
• Alcohol should be consumed with food to reduce risk of hypoglycemia.
• Alcohol should never be mixed with chlorpropamide (Diabinese).
• Abstention from alcohol is recommended for women during pregnancy and those with medical problems such as pancreatitis, advanced neuropathy, severe hypertriglyceridemia, or alcohol abuse.