Diabetes dietary recommendations of american dietetic association


 * Associate Editor(s)-In-Chief: Priyamvada Singh, M.B.B.S. [mailto:psingh@perfuse.org];

Overview
==American Dietetic Association: General Nutrition Recommendations (DO NOT EDIT)  == {{cquote|

MNT (medical nutrition therapy) and Number/Length of Initial Series of Encounters
MNT (medical nutrition therapy) provided by a RD (registered dietitian) is recommended for individuals with type 1 and type 2 diabetes. An initial series of three to four encounters each lasting from 45 to 90 minutes is recommended. This series, beginning at diagnosis of diabetes or at first referral to an RD for MNT for diabetes, should be completed within three to six months. The RD should determine if additional MNT encounters are needed after the initial series based on the nutrition assessment of learning needs and progress towards desired outcomes.

Strong, Imperative

MNT Long-Term Follow-up Encounters
At least one follow-up encounter is recommended annually to reinforce lifestyle changes and to evaluate and monitor outcomes that impact the need for changes in MNT or medication. The RD should determine if additional MNT encounters are needed.

Strong, Imperative

Recommendations Strength Rationale
 * Conclusion statement was Grade I

DM: Assessment and Diabetes
Nutrition Assessment

The RD should assess food intake (focusing on carbohydrate), medication, metabolic control (glycemia, lipids, and blood pressure), anthropometric measurements and physical activity to serve as the basis for implementation of the nutrition prescription, goals and intervention. Individuals who have diabetes should receive MNT tailored by the RD.

Strong, Imperative

Recommendations Strength Rationale
 * Conclusion statement was Grade I

DM: Assessment of Glycemic Control
The RD should assess glycemic control and focus MNT to achieve and maintain blood glucose levels in the target range (target glucose levels noted in the American Diabetes Association Standards of Medical Care in Diabetes).

Strong, Imperative

Recommendation Strength Rationale
 * Conclusion statement was Grade I

DM: Assess Relative Importance of Weight Management
The RD should assess the relative importance of weight management for persons with diabetes who are overweight or obese. While modest weight loss has been shown to improve insulin resistance in overweight and obese insulin-resistant individuals, research on sustained weight loss interventions lasting 1 year or longer reported inconsistent effects on A1C.

Strong, Conditional

Recommendation Strength Rationale
 * Conclusion statement was Grade II

DM: Intervention Options
The RD should implement MNT selecting from a variety of interventions (reduced energy and fat intake, carbohydrate counting, simplified meal plans, healthy food choices, individualized meal planning strategies, exchange lists, insulin-to-carbohydrate ratios, physical activity and behavioral strategies). Nutrition education and counseling should be sensitive to the personal needs, willingness to change, and ability to make changes of the individual with diabetes.

Strong, Imperative

Recommendation Strength Rationale
 * Conclusion statement was Grade I

DM: Macronutrients
The RD should encourage consumption of macronutrients based on the Dietary Reference Intakes (DRI) for healthy adults. Research does not support any ideal percentage of energy from macronutrients for persons with diabetes.

Strong, Imperative

Recommendation Strength Rationale
 * Conclusion statement for Carbohydrate was Grade I
 * Conclusion statement for Protein was Grade II

DM: Carbohydrate

In persons on either MNT alone, glucose-lowering medications or fixed insulin doses, meal and snack carbohydrate intake should be kept consistent on a day-to-day basis. Consistency in carbohydrate intake results in improved glycemic control.

Strong, Conditional

Carbohydrate Intake and Insulin Dose Adjustment
In persons with type 1 or type 2 diabetes who adjust their mealtime insulin doses or who are on insulin pump therapy, insulin doses should be adjusted to match carbohydrate intake (insulin-to-carbohydrate ratio). This can be accomplished by comprehensive nutrition education and counseling on interpretation of blood glucose patterns, nutrition-related medication management and collaboration with the healthcare team. Adjusting insulin dose based on planned carbohydrate intake improves glycemic control and quality of life without any adverse effects.

Strong, Conditional

Recommendation Strength Rational
 * Conclusion statement was Grade I

DM: Sucrose and Diabetes
If persons with diabetes choose to eat foods containing sucrose, the sucrose-containing foods should be substituted for other carbohydrate foods. Sucrose intakes of 10 to 35 percent of total energy intake do not have a negative effect on glycemic or lipid responses when substituted for isocaloric amounts of starch.

Strong, Conditional

Recommendation Strength Rationale
 * Conclusion statement was Grade I

DM: Non-nutritive Sweeteners and Diabetes
If persons with diabetes choose to consume products containing U.S. FDA-approved non-nutritive sweeteners, at levels that do not exceed the acceptable daily intakes (ADIs), the RD should advise that some of these products may contain energy and carbohydrate from other sources that needs to be accounted for. Research on non-nutritive sweeteners reports no effect on changes in glycemic response.

Fair, Conditional

Recommendation Strength Rationale
 * Conclusion statements were Grade III

DM: Glycemic Index and Diabetes
If the use of glycemic index (GI) is proposed as a method of meal planning, the RD should advise on the conflicting evidence of effectiveness of this strategy. Studies comparing high versus low GI diets report mixed effects on A1C.

Fair, Conditional

Recommendation Strength Rationale
 * Conclusion statement was Grade II

DM: Fiber and Diabetes
Recommendations for fiber intake for people with diabetes are similar to the recommendations for the general public (DRI: 14 grams per 1000 kcal). While diets containing 44 to 50 grams of fiber daily are reported to improve glycemia; more usual fiber intakes (up to 24 grams daily) have not shown beneficial effects on glycemia. It is unknown if free-living individuals can daily consume the amount of fiber needed to improve glycemia.

Strong, Imperative

Fiber Intake and Cholesterol
Include foods containing 25 to 30 grams of fiber per day, with special emphasis on soluble fiber sources (7 to 13 grams). Diets high in total and soluble fiber, as part of cardioprotective nutrition therapy, can further reduce total cholesterol by 2% to 3% and LDL cholesterol up to 7%.

Strong, Imperative

Recommendation Strength Rationale
 * Conclusion statement for Fiber and Diabetes was Grade I
 * Conclusion statement for Fiber and Coronary Heart Disease (CHD) were Grades I, II, and III

DM: Protein and Diabetes
In persons with type 1 or type 2 diabetes with normal renal function, the RD should advise that usual protein intake of approximately 15% to 20% of daily energy intake does not need to be changed. Although protein has an acute effect on insulin secretion, usual protein intake in long-term studies has minimal effects on glucose, lipids, and insulin concentrations.

Fair, Conditional

Recommendation Strength Rationale
 * Conclusion statements were Grade II

DM: Glucose Monitoring
For individuals on nutrition therapy alone or nutrition therapy in combination with glucose-lowering medications, SMBG is recommended. Frequency and timing is dependent on diabetes management goals and therapies (i.e., MNT, diabetes medications and physical activity). When SMBG is incorporated into diabetes education programs and the information from SMBG is used to make changes in diabetes management, SMBG is associated with improved glycemic control.

Fair, Conditional

Frequency of Blood Glucose Monitoring

For persons with type 1 or type 2 diabetes on insulin therapy, at least three to eight blood glucose tests per day are recommended to determine the adequacy of the insulin dose(s) and guide adjustments in insulin dose(s), food intake and physical activity. Some insulin regimens require more testing to establish the best integrated therapy (insulin, food, and activity). Once established, some insulin regimens will require less frequent SMBG. Intervention studies that include self-management training and adjustment of insulin doses based on SMBG result in improved glycemic control.

Strong, Conditional

Possible Need for Continuous Glucose Monitoring or More Frequent SMBG

Persons experiencing unexplained elevations in A1C or unexplained hypoglycemia and hyperglycemia may benefit from use of CGM or more frequent SMBG. It is essential that persons with diabetes receive education as to how to calibrate CGM and how to interpret CGM results. Studies have proven the accuracy of CGM and most show that using the trend/pattern data from CGM can result in less glucose variability and improved glucose control.

Fair, Conditional

Recommendation Strength Rationale
 * Conclusion statements were Grades I and II

DM: Coordination of Care and Diabetes
The RD should implement MNT and coordinate care with an interdisciplinary team. An interdisciplinary team approach is necessary to integrate MNT for patients with diabetes into overall management.

Consensus, Imperative

Recommendation Strength Rationale
 * Conclusion statement was Grade I

DM: Monitor & Evaluate and Diabetes
The RD should monitor and evaluate food intake, medication, metabolic control (glycemia, lipids, and blood pressure), anthropometric measurements and physical activity. Research reports sustained improvements in A1C at 12 months and longer with long-term follow-up encounters with an RD.

Strong, Imperative

Evaluation of Glycemic Control

The RD should primarily use blood glucose monitoring results in evaluating the achievement of goals and effectiveness of MNT. Glucose monitoring results can be used to determine whether adjustments in foods and meals will be sufficient to achieve blood glucose goals or if medication additions or adjustments need to be combined with MNT.

Consensus, Imperative

Recommendation Strength Rationale
 * Conclusion statement for MNT was Grade I

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