ADA’s Nutrition Guidelines

 

Diabetes management necessarily involves a number of key factors like, preserving heart health, regular exercising, and following a healthy diet which is the most frustrating part for many diabetic patients! Well, it does not have to be, patients can now plan their own dietary system with the help of a registered dietitian 

You are not alone!

As a diabetic patient try to share your experience with others who also face the same challenges related to healthy eating, especially on special occasions and during vacations.

 

What are the key targets of nutrition therapy?

 

  • Keeping eating pleasure uninterrupted by providing a variety of choices unless otherwise is indicated 
  • Providing a dietary system that is tailored to the needs and preferences of people with diabetes, and considers their ability to change their eating habits
  • Offering applicable tools for planning daily meals
  • Encouraging and enhancing healthy eating habits focusing on consuming foods which are rich with nutrients in the right proportions, to maintain the patient’s  blood pressure at <140/80 mmHg, glycemic level at<7% and lipid levels at LDL cholesterol <100 mg/dL; triglycerides <150 mg/dL; HDL cholesterol >40 mg/dL for men; HDL cholesterol >50 mg/dL  for women. Besides a healthy diet would help in controlling body weight and circumventing diabetes complications

 

Important tips:

  • Maintaining glycemic level within range may also involve other factors such as diabetes duration, age, …etc).
  • preserving blood pressure, lipid levels and glycemic level plays an important role in reducing the risk of microvascular complications
  • Managing metabolic rate is indispensable for diabetes treatment
  • Food choices affect blood pressure, lipid and energy levels 

 

Can we consider nutrition therapy a part of diabetes care?

In theory, all people diagnosed with diabetes should check with a registered dietitian or join a comprehensive diabetes self-management education program upon diagnosis or immediately after, however, this is not the case with the majority of diabetic patients and many of them have no idea that such services are already accessible to them. Therefore, the Institute of Medicine (IOM) indicated in its report issued in 1999 that medical nutrition therapy can help enhance diabetes clinical results and suggested that it should be included in the Medicare program as a part of diabetes care

According to (IOM) the term “nutrition therapy” is more comprehensive than “medical nutrition therapy”, which is defined as “the treatment of a disease or condition through the modification of nutrient or whole-food intake”

Is nutrition therapy effective?

Nutrition therapy represents a part of the treatment protocol of people diagnosed with type 1 and types 2 diabetes, each patient should receive personalized medical nutrition therapy by a registered dietitian. Type 1 diabetic patients should join a  flexible insulin therapy education program and plan meals that observe carbohydrate consumption, to enhance glycemic control. On the other hand, planning meals is a better approach for type 2 diabetic patients who lack numeracy literacy skills or senior patients.

Nutrition therapy plays a key role in managing diabetes as it helps reduce glucose level, control blood pressure  and lipid ratio, in addition to decreasing the risk of stroke, cardiovascular disease, and coronary heart disease

Based on randomized controlled trials (RCTs) and Cochrane’s studies, nutrition therapy is said to be effective in promoting glycemic control, signs of cardiovascular and hypertension risk. In general, statistics also indicate that medical nutrition therapy helps people with lipid disorders control fat levels.

 

How does nutrition therapy affect the process of diabetes self-management education and support?

Diabetes Self-Management Education (DSME) and Diabetes Self-Management Support (DSMS)  constitute an essential part of diabetes treatment. The National Standards for Diabetes Self-Management Education and Support and The American Association of Diabetes emphasize the significance of nutrition in diabetes care programs 

Energy Balance:

Type 2 diabetic patients who also suffer from obesity have to lower their energy input and follow a healthy diet. Losing weight in a moderate manner may result in controlling lipid ratio, blood pressure and glycemia for many diabetic patients.

The great majority of people with diabetes suffer from various degrees of obesity, due to the connection between adiposity and insulin resistance, weight loss and avoiding weight gain become a prerequisite. This prerequisite is usually difficult to fulfill because of the influence of certain diabetes medications.

Changing eating habits, low glycosuria and the change in the exerted physical effort

contribute to adiposity in diabetic patients.

 An energetic lifestyle helps greatly in reducing excessive weight, improving  A1C and maintaining blood pressure and lipid levels within the target range, people at the initial stage of diabetes are more likely to achieve better results and many of them reached a partial or even full recovery 

Is maintaining weight after weight loss possible?

Many patients regain some of the weight they had initially lost for various reasons such as the lack of support, socioeconomic circumstances, and physiological changes. However, they still can maintain their weight if they receive prolonged support. No specific nutrition therapy pattern was proved to help with weight loss, there is a variety of eating patterns that contribute to decreasing energy input. Caregivers should encourage diabetic patients to adopt dietary practices that aim to stop weight gain and enhance moderate weight loss. Bariatric surgery can be a valid choice 

 

What is the dietary pattern?

A dietary pattern stands for grouping different foods in a meal, it signifies the relation between nutrition and good health. Diabetic patients may plan their own diet according to their own preferences provided that metabolic goals are observed. A dietary pattern is usually influenced inter alia by the patient’s cultural background, awareness, and access to healthy food…

    1. The Mediterranean dietary pattern: Studies suggest that the Mediterranean dietary pattern protects against cardiovascular diseases  (CVD) risk factors in diabetes patients who are susceptible to strokes and CVDs. Moreover, the Mediterranean dietary pattern helps in controlling glucose levels.
    2. The vegan/vegetarian pattern: It was not proven to enhance glycemic control or reduce CVD risk factors unless in combination with weight loss and limiting energy intake 

 

  • The low-fat pattern: This pattern is usually approved as a weight-loss technique which helps in promoting heart health, yet it did not seem to help with glycemic control or CVD risk factors
  • Low-carbohydrate pattern: no evidence yet proving that consuming a certain amount of calories would help with the treatment of diabetes. Nevertheless, the DASH pattern helps in decreasing CVD risk and maintaining blood pressure within normal limits in general 

 

To conclude, there is no specific eating pattern that fits all diabetic patients, planning an eating pattern is influenced by several factors most important of which is the energy input.

 

Is there an ideal macronutrient combination?

A systematic study showed that there is no what can be called an ideal macronutrient combination for all diabetic patients, proportions distribution is a matter of eating habits and preferences provided that metabolic goals are considered. Macronutrients combination depends on the patient’s metabolic condition, none of the above mentioned dietary patterns was proved to have much influence on diabetes management 

Personalized macronutrients:

 

  • Carbohydrates:

 

There is no solid proof dictating the amount of carbohydrate a diabetic patient should consume, yet carbohydrate amount and insulin ratio should be taken into account when planning the dietary pattern. Carbohydrate intake from whole grains, vegetables, and fruits are preferred over the other sources with added fats, sodium and sugar

Studies conducted to compare lower carbohydrate consumption to higher carbohydrate consumption, showed enhancement of glycemic control and insulin sensitivity with the lower carbohydrate diet, while a number of randomized controlled trials showed no remarkable difference. Other studies indicated developments in serum lipid/lipoprotein measures with lower carbohydrate consumption, whereas a few studies indicated no difference, yet it should be stressed here that these studies were all small and short-duration. However, it is well established that the type and amount of carbohydrate affect blood glucose level and glycemic response

Carbohydrates quality

Glycemic Index and glycemic load

This issue is relatively confusing, studies define low and high glycemic index in many ways, also glycemic response towards  a certain food differs from one patient to the other beside it can be influenced by the food combination consumed

Replacing low–glycemic load foods with higher–glycemic load foods may lead to a slight development in glycemic control and cardiovascular diseases risk measures 

Dietary Fiber and Whole Grains

The studies on fiber intake are mostly conducted within a short span of time on a limited sample hence their outcomes regarding fiber influence in enhancing glycemic control or CVD risk factors, are not reliable. 

Low calories sweeteners and NonnutritiveSweeteners

The American Food and Drug Administration approves the consumption of nonnutritive sweeteners (NNSs) both for diabetic and non-diabetic people. Although NNSs are known to lower calorie and carbohydrate intake if used alone as a substitute for caloric sweeteners, it is established that they do not influence blood sugar, body weight or decrease cardiometabolic risk factors

Resistant starch and fructans

No solid prolonged studies were found to support the benefit of consuming resistant or fructans starch for people with diabetes 

What happens if starch is replaced by sucrose?

Studies suggest that replacing starch with sucrose ( table sugar) for a maximum of 35% of consumed calories has no remarkable effect on  blood glucose or lipid ratio, a healthy diet pattern should be followed to avoid raising calorie intake 

Fructose

Free fructose taken from natural sources like fruits is not likely to increase the triglycerides in blood if consumed in the right proportion and may enhance glycemic control. Studies revealed that consumption of free fructose is as harmless as any other sugar, as long as it is consumed within appropriate limits. Diabetic patients should be very cautious about consuming sugar-sweetened beverages and foods containing a large amount of fructose. According to the researches of Cozma et al., replacing fructose with carbohydrates decreased glycated blood proteins but had no remarkable effect on sting glucose or insulin

Protein

  • Diabetic patients who do not suffer  from kidney disease, no pattern for protein consumption is recommended
  • Patients who are diabetic and have kidney disease should not decrease their consumption of protein than usual 
  • type 2 diabetic patients should not consume carbohydrate  foods high in protein 

Total Fat

No consumption amount is recommended, quality is more significant 

Monounsaturated Fatty Acids/ Polyunsaturated Fatty Acids

People with type 2 diabetes are advised to follow the Mediterranean dietary pattern, as it promotes glycemic control, \improves CVD risk or risk factors and blood lipids

Saturated Fat (SFAs ), Dietary Cholesterol, and Trans Fat

Diabetic people may consume the same quantity of cholesterol, trans fat and saturated fat, like anyone else, i.e.  SFAs should be decreased to less than 10% of calories, below 300 mg dietary cholesterol/day, and minimizing trans fat as much as they can

Omega-3 Fatty Acids

Consuming more foods containing long-chain omega-3 fatty acids, and omega-3 linolenic acid, as well as, eating fish twice a week is equally recommended for diabetic and non-diabetic people. However, diabetic people should not take omega-3 supplements

Micronutrients and Herbal Supplements

It was not established that supplements, minerals or vitamins are useful for diabetic patients unless certain deficiency was detected. Furthermore, consumption of micronutrients or herbs is not particularly recommended for people with diabetes, instead they may fulfill their needs of vitamins and minerals from natural sources. For certain patients such as pregnant women, seniors… multivitamins may be used   

Plant Stanols and Sterols

Plant stanols or sterols are found to moderately decrease total and LDL cholesterol for people with dyslipidemia and diabetes, yet cautious should be taken when consuming foods containing plant stanols /sterols as they are high in calories.

Sodium

It is generally advised to lower sodium consumption to below 2,300 mg/day, and diabetic people are no exception especially if they also suffer from hypertension 

 

Alcohol

Alcohol consumption represents a risk for diabetic adults, thus daily consumption may not exceed one drink for women and two drinks for men. It should be forbidden under certain conditions like pregnancy, liver disorder, and severe hypertriglyceridemia

 

 

 

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