American Diabetes Association Guide to Nutrition Therapy for Diabetes

Chapter 1: Effectiveness of Nutrition Therapy and Healthy Eating Interventions in Diabetes Management

Joyce Green Pastors, MS, RDN, CDE

Highlights

Medical Nutrition Therapy and Healthy Eating Definitions

Evidence for the Effectiveness of Nutrition Therapy and Healthy Eating Interventions

Other Metabolic Outcomes Improved with Nutrition Therapy

Variables That Impact Effectiveness of Nutrition Therapy

Summary of Nutrition Therapy and Healthy Eating Interventions

HIGHLIGHTS

EFFECTIVENESS OF NUTRITION THERAPY AND HEALTHY EATING INTERVENTIONS IN DIABETES MANAGEMENT

• Medical nutrition therapy (MNT) is an evidence-based application of the Nutrition Care Process by a registered dietitian nutritionist (RDN) and is the legal definition of nutrition counseling provided by an RDN in the U.S., but it is generally referred to as nutrition therapy in countries outside the U.S. Both MNT and nutrition therapy involve a process that includes a nutrition assessment, nutrition diagnosis, nutrition interventions (education, counseling, and goal-setting), and nutrition monitoring and evaluation.

• Healthy eating is a pattern of eating a wide variety of high-quality, nutrient-dense foods in quantities that promote optimal health and wellness. It is one of the seven specific self-care behaviors known as the AADE7 Self-Care Behaviors. Many health-care professionals can provide guidance for healthy eating and all need to support individuals as they change eating habits.

• Medical nutrition therapy for the treatment of diabetes is effective, with the greatest impact at the initial onset of diabetes. Randomized controlled trials and observational studies have shown that within the first 6 months of diagnosis, A1C can be reduced up to ~2% point reductions (range 0.3–2.0%), depending on the baseline A1C level and the duration of diabetes. However, MNT is effective throughout the diabetes disease process; at >12 months, with ongoing RDN support, continued A1C decreases ranging from 0.6% to 1.8% are reported.

• There are many types of diabetes nutrition therapy interventions that can be effectively used by an RDN; these interventions involve individualization of calories and nutrients (carbohydrate, protein, fat), and can include eating plans, sample menus, carbohydrate counting, and food choice lists.

• In type 1 diabetes, carbohydrate counting and using insulin-to-carbohydrate ratios to adjust premeal insulin doses based on planned carbohydrate intake should be the primary focus for glycemic control. For people with type 2 diabetes, the focus should be on improving the quality of eating through healthy, nutrient-dense food choices, and reducing energy intake.

• Healthy eating and weight loss are the keys to prevention of type 2 diabetes and are important for individuals newly diagnosed with diabetes. Healthy eating using a variety of eating patterns can help improve the quality of a person’s food choices and improve clinical outcomes.

• Eating plans rich in whole grains, fruits, vegetables, legumes, and nuts; moderate in alcohol consumption; and lower in refined grains, processed meats, and sugar-sweetened beverages (which should be completely avoided) have been shown to reduce the risk of type 2 diabetes and improve glycemic control and lipid levels in people with diabetes.

• Eating patterns that have been associated with lower incidence of type 2 diabetes include Mediterranean, low-fat, DASH (Dietary Approaches to Stop Hypertension), and vegetarian/vegan diets.

• Selecting the most appropriate nutrition therapy intervention and eating pattern is a collaborative process and involves self-directed goal setting with the individual. It also includes use of educational and behavioral tools and strategies tailored to each individual with diabetes.

• A minimum of three to six initial nutrition therapy sessions is recommended during the first 6 months after diagnosis. At least one annual follow-up session for nutrition therapy should be provided.

Effectiveness of Nutrition Therapy and Healthy Eating Interventions in Diabetes Management

Since the discovery of sweet urine in ancient Egypt approximately 3,000 years ago, people with diabetes have been given advice on what to eat and drink, often based more on theories or beliefs than on facts. Food and nutrition advice has ranged from starvation diets to high- or low-carbohydrate or low-fat diets to nutritional supplements that will provide a cure.

In recent years, the goal in the development of diabetes nutrition therapy recommendations has been to have the recommendations be based on evidence rather than theories. For example, until relatively recently, it was long-standing advice that people with diabetes should not eat sugar or foods containing sugars. This information was based on the assumption that because sugars were small molecules, they would be absorbed rapidly, causing blood glucose levels to increase at a greater rate than starches (which are larger molecules). When research first revealed that total amount of carbohydrate was more important than the source,¹ the public and many health-care professionals were surprised. However, almost all diabetes nutrition recommendations now acknowledge that simple carbohydrates (such as sugar), in moderation, can be substituted for complex carbohydrates.

Various professional organizations have published nutrition recommendations on the basis of available research and clinical observations. From 2011–2013, the U.S., Canada, and the United Kingdom have all published evidence-based nutrition guidelines for diabetes that promote individualized goals and a focus on the quality of macronutrient intake in addition to the quantity or distribution of nutrients.²–⁵

The goals of diabetes nutrition therapy are to promote healthful eating patterns that provide a variety of nutrient-dense foods; support individualized nutrition needs based on personal and cultural preferences, health literacy, access to healthy foods, willingness and ability to change eating behaviors, and barriers to change; maintain the pleasure of eating; and implement practical educational tools for food/meal planning rather than focusing on nutrients or single foods. The primary purpose of these goals is to achieve positive clinical outcomes—specifically, to attain individualized glycemic, blood pressure, and lipid goals; to attain and maintain body-weight goals; and to delay or prevent complications of diabetes.³

The primary question then becomes, What is the evidence that nutrition therapy and healthy eating interventions are effective and can achieve these outcomes? Secondary questions include: What variables need to be considered as factors in effectiveness? What nutrition interventions or eating patterns should be recommended, and how should they be selected and individualized for persons with diabetes? It is important that all diabetes health-care professionals know what outcomes can be achieved from the implementation of these interventions, other variables to be considered, and what specific interventions contribute to successful outcomes.

MEDICAL NUTRITION THERAPY AND HEALTHY EATING DEFINITIONS

Before we can begin the discussion of the effectiveness of nutrition therapy in diabetes, we must first differentiate between medical nutrition therapy (MNT) and healthy eating.

MNT is an evidence-based application of the Nutrition Care Process (nutrition assessment, nutrition diagnosis, nutrition intervention, nutrition monitoring and evaluation) performed by a registered dietitian nutritionist (RDN) and is the legal definition of nutrition counseling provided by an RDN in the U.S.⁶ In countries outside the U.S., this is not a legal definition, so the broader definition of nutrition therapy is often used. The focus of both MNT and nutrition therapy is on the individualized implementation of evidence-based nutrition therapy recommendations and practice guidelines in collaboration with the person with diabetes.²,³

MNT utilizing the Nutrition Care Process involves the following steps: 1) nutrition assessment; 2) nutrition diagnosis; 3) nutrition interventions that include education, counseling, and goal setting; and 4) nutrition monitoring and evaluation with ongoing follow-ups to support long-term lifestyle changes, evaluation of outcomes, and monitoring of interventions as needed.⁷ The RDN (or a similarly credentialed nutrition professional if outside the U.S.) has the academic preparation, training, skills, and expertise to be the preferred team member to provide nutrition therapy.³

The American Diabetes Association nutrition therapy recommendations state that healthy eating can be defined as a pattern of eating a wide variety of high-quality, nutrient-dense foods in quantities that promote optimal health and wellness.³ The focus for healthy eating should be more on the quality of food choices and less on nutrition percentages. Many health-care professionals can provide guidance for healthy eating but all need to support individuals as they change eating habits.⁸ A review of healthy eating published as a synopsis paper by the American Association of Diabetes Educators (AADE) suggested that there is no ideal macronutrient distribution, but rather that healthy eating should be based on an individualized assessment of current eating patterns, preferences, and metabolic goals.⁸ In addition, emphasis should be placed on healthful eating patterns, emphasizing a variety of nutrient-dense foods in appropriate portion sizes.³ The AADE recommends that all people with diabetes see an RDN for MNT at diagnosis and as needed thereafter, but all diabetes educators have the important role of assessing needs and providing basic information and ongoing support focusing on healthy eating habits, and all health-care providers should also provide support.

Nutrient density is a measure of the amount of nutrients a food contains compared with the number of calories. A food is more nutrient dense when the level of nutrients is high in relation to the number of calories the food contains. Nutrient-dense food choices include the following:

• Grains, especially whole grains

• Fruits and vegetables: fresh, frozen, or canned (fruits in fruit juice and vegetables labeled as light or low sodium)

• Fat-free or low-fat milk or dairy-like products

• Lean protein sources or meat alternatives such as beans, lentils, and unsalted nuts

• Substituting unsaturated fats (liquid fats such as olive, canola, corn, or safflower oil) for foods higher in saturated (solid fats) or trans fats as much as possible

EVIDENCE FOR THE EFFECTIVENESS OF NUTRITION THERAPY AND HEALTHY EATING INTERVENTIONS

Evidence to answer the primary question—what is the evidence that nutrition therapy and healthy eating interventions are effective?—comes from randomized controlled trials and observational and outcome studies showing that nutrition therapy interventions improve metabolic outcomes, such as blood glucose and hemoglobin A1c (A1C), in individuals with diabetes. Randomized controlled trials are considered the gold standard for evidence. However, when assessing the impact of an intervention in clinical practice, these trials have limitations. First and foremost, subjects are selected (and rejected) usually on their perceived ability to complete the study. In clinical practice, patients are generally offered care regardless of their interest and ability to make lifestyle changes. Outcome or observational studies usually provide outcome data from all patients entered into patient care and thus are often a more realistic report on expected outcomes from clinical care. However, these studies are frequently criticized for their lack of rigorous study design. In general, useful data can be collected from both types of study designs.

In this chapter, we have chosen to summarize the results that have been reported in evidence-based analyses, systematic reviews, and meta-analysis studies. The specific randomized controlled trials and other observational studies will be reviewed in subsequent chapters on type 1 diabetes nutrition therapy, and type 2 diabetes nutrition therapy. Table 1.1 summarizes the evidence-based analyses, systematic reviews, and meta-analyses that have been published in regard to effectiveness of MNT, healthy eating, and combined interventions for diabetes management,²,⁹-¹¹ and that are reviewed in the next sections.

Table 1.1 Summary of Evidence-Based Analyses, Systematic Reviews, and Meta-Analyses: Effectiveness of Nutrition Therapy and Healthy Eating in Diabetes

A1C, hemoglobin A1c; FBG, fasting blood glucose; BP, blood pressure; EAL, Evidence Analysis Library; T2D, type 2 diabetes; T1D, type 1 diabetes; RCT, randomized controlled trial; CHO, carbohydrate; MNT, medical nutrition therapy; DCCT, Diabetes Control and Complications Trial; LDL, low-density lipoprotein cholesterol; NS, nonsignificant; TG, triglycerides; DBP, diastolic blood pressure; SBP, systolic blood pressure; MUF, monounsaturated fat; PA, physical activity.

* Variables that impact effectiveness of MNT include duration of diabetes, level of glucose control, number of nutrition therapy sessions, and type of nutrition intervention.

** Combined intervention studies include MNT with diabetes self-management education and MNT with behavior modification and PA.

Effectiveness of Medical Nutrition Therapy

Many studies have now been published providing evidence that MNT is effective in improving glycemic control (A1C/fasting blood glucose) in persons with type 1 or type 2 diabetes. The Academy of Nutrition and Dietetics’ (Academy) systematic review of evidence for the Diabetes Mellitus Type 1 and Type 2 in Adult Nutrition Practice Guidelines is published in the Academy’s Evidence Analysis Library.² In adults with type 2 diabetes, 18 studies reported that nutrition therapy provided by a registered dietitian nutritionist (RDN) lowered A1C levels. Three months after nutrition therapy was implemented, A1C levels decreased from 0.3– 2.0%. In an additional eight studies reporting fasting blood glucose levels in type 2 diabetes, nutrition therapy decreased fasting blood glucose levels at 3 months by 18–61 mg/dL. With continued nutrition support, decreases in A1C levels (0.6–1.8%) were improved or maintained for more than 12 months. In adults with type 1 diabetes, three studies reported that nutrition therapy provided by RDNs contributed to significantly decreased A1C levels at 6 months (1.0–1.9%). These levels were maintained at one year with nutrition support and in the Diabetes Control and Complications Trial (DCCT), throughout the 6.5 years of the trial.²

These studies also showed that there were benefits of nutrition therapy on other metabolic outcomes, including weight loss/body mass index (BMI)/waist circumference, improved lipid profiles, decreased blood pressure, and decreased risk of onset and progression to diabetes-related comorbidities.²,³,⁹,¹⁰ In addition, strong evidence reports improved quality of life outcomes (improvements in self-perception of health status, knowledge, and motivation, satisfaction with treatment, psychological well-being).² In persons with type 2 diabetes, strong evidence reports decreases in doses and/or number of glucose-lowering medications. In persons with type 1 diabetes, although the number of daily insulin injections increased with MNT, A1C improved without an increase in total daily insulin dose.²

Effectiveness of Healthy Eating

In a systematic review and meta-analysis of different dietary approaches in the management of type 2 diabetes, low-carbohydrate, low–glycemic index, Mediterranean, and high-protein diets were shown to be effective in improving glycemic control, with the largest effect size seen in the Mediterranean diet.¹⁰ The low-carbohydrate and Mediterranean diets led to greater weight loss, and an increase in HDL lipid levels was seen in all diets except the high-protein diet.

The American Diabetes Association reviewed several research studies looking at eating patterns in people with diabetes and concluded that a variety of eating patterns are acceptable for the management of diabetes.³ In a systematic review of eating patterns conducted in 2010, those that showed evidence of improvements in glycemic control, weight loss, and/or cardiovascular risk factors included the Mediterranean-style, vegetarian/vegan, low-fat, and the DASH eating plans.¹² The patient’s personal preferences (e.g., tradition, culture, religion, health beliefs and goals, economics, etc.) and metabolic goals should be considered when recommending one eating pattern over another.³

Evidence suggests that there are no ideal percentages of calories from carbohydrate, protein, and fat for all people at risk for or with diabetes. The quality of fat and carbohydrate may be more important than the quantity of these macronutrients.¹³ Greater intake of omega-6 polyunsaturated fat has been associated with lower diabetes risk,¹⁴ and replacement of saturated fat with omega-6 has been related to a lower risk of developing diabetes.¹⁵ A meta-analysis showed an inverse association between high-fiber cereal products and the risk of type 2 diabetes.¹⁶ In a meta-analysis of prospective studies, low–glycemic index (GI) and low–glycemic load (GL) diets were associated with lower risk of diabetes than diets with a higher GI and GL, independent of the amount of cereal fiber in the diet.¹⁷ Macronutrient distribution should be based on individualized assessment of current eating patterns, preferences, and metabolic goals. Emphasis is placed on high-quality, minimally processed foods.⁸ Furthermore, eating patterns are developed in collaboration with the individual with diabetes.

OTHER METABOLIC OUTCOMES IMPROVED WITH NUTRITION THERAPY

Body Weight/Body Fat

In MNT studies provided by RDNs that have reported body weight and body fat outcomes, results have been mixed.² In 11 study arms with type 2 diabetes, five reported significant decreases in body weight from baseline by 2.4–6.2 kg. but six study arms reported nonsignificant weight changes at the end of the study. In persons with type 1 diabetes, weight outcomes were also mixed. In studies reporting BMI, nine study arms reported significant decreases from 0.3–2.1 kg/m², whereas eight study arms reported nonsignificant changes in BMI at the end of the study. In persons with type 1 diabetes, one study reported a significantly decreased BMI of 0.3 kg/m². In studies reporting waist circumference outcomes in type 2 diabetes, nine study arms reported decreases of 1.0–5.5 cm and three study arms reported nonsignificant changes in waist circumference at the end of the study. In persons with type 1 diabetes, one study reported a significant decrease in waist circumference of 1.0 cm.²

Lipid Profiles

In studies of people with type 2 diabetes who reported normal to mildly elevated lipid profiles, results with MNT provided by RDNs have also been mixed.² Eight studies reported significant decreases in cholesterol (ranges of 8–38 mg/dL) and 16 studies reported mixed effects on cholesterol. Seven studies reported significant decreases in LDL cholesterol ranging from 8–22 mg/dL and 15 studies reported mixed effects. Three studies reported significant increases in HDL cholesterol from a range of 2.4–6.0 mg/dL and 16 studies reported mixed effects. Seven studies reported significant decreases in triglycerides (15–153 mg/dL) and 16 studies reported mixed effects. However, the effectiveness of MNT may have been confounded by the frequent use of lipid-lowering medications.²

Blood Pressure

Blood pressure levels reported in studies with MNT provided by RDNs have also shown mixed effects.² In adults with type 2 diabetes who had near-normal blood pressure levels, seven studies reported significant decreases in systolic and diastolic blood pressure of 9.0–5.3 mmHg and 3.2–2.5 mmHg, respectively, and 10 studies reported mixed effects on blood pressure. These studies may also be confounded by frequent use of anti-hypertension medications.²

Other Outcomes

In addition, improvements in quality of life have been reported in six studies when MNT intervention was provided by RDNs.² Decreases in the dose or number of glucose-lowering medications were reported in 11 studies in persons with type 2 diabetes. The United Kingdom Prospective Diabetes Study demonstrated significantly improved glucose outcomes for ~2 years; due to the progression of type 2 diabetes, additional medications were needed over time to achieve optimal control.¹⁸ Weight gain commonly reported with insulin use also can be minimized with intensive nutrition therapy intervention.²

VARIABLES THAT IMPACT EFFECTIVENESS OF NUTRITION THERAPY

Several other variables have been reported in research studies that also affect and impact the results, regarding outcomes, when evaluating the effectiveness of nutrition therapy. These variables include the duration of diabetes; the level of glycemic management at implementation; the number of nutrition therapy sessions; the type of nutrition therapy intervention; and other interventions combined with nutrition therapy (i.e., diabetes self-management education (DSME), behavior therapy, and/or physical activity/exercise).

Duration of Diabetes and Level of Glycemia

Nutrition therapy in newly diagnosed people with type 2 diabetes with A1C levels of ~9% significantly lowered A1C by 2%; for those newly diagnosed with A1C levels of ~6.6%, there were also significant decreases of 0.4% with nutrition therapy. Both results are clinically significant.³,⁹ Even in people with a duration of type 2 diabetes of ~9 years, who are not in optimal glycemic control, nutrition therapy decreased A1C levels by ~0.5%, which was also significant and equivalent to adding a third diabetes medication (though nutrition therapy was more cost-effective).¹⁹

Outcomes resulting from nutrition interventions are generally known in 6 weeks to 3 months, and evaluation should be performed at these times. At 3 months, if no clinical improvement has been seen in metabolic outcomes (glucose, weight, lipids, blood pressure), usually a change in medication(s) is needed. Type 2 diabetes is a progressive disease, and as β-cell function decreases, glucose-lowering medication(s), including insulin, must be combined with MNT to achieve target goals. The evidence suggests that MNT is most beneficial at initial diagnosis, but is effective at any time during the disease process, and that ongoing evaluation and intervention are essential.⁹

Nutrition Therapy Sessions

In studies that have reported the number of educational sessions provided by an RDN, there was a range of 3–11 sessions and a total hourly range of 2–16 hours. In the first 6 months, MNT significantly decreased A1C levels from 0.3–2.0% in persons with type 2 diabetes and from 1.0–1.9% in persons with type 1 diabetes. Studies longer than 6 months report that continued MNT sessions resulted in maintenance and/or continued decreases of A1C for up to 2 years in adults with type 2 diabetes, and for up to 6.5 years in persons with type 1 diabetes.²,¹¹

The Academy recommends that RDNs utilizing the Nutrition Care Process should implement a minimum of three to six MNT sessions during the first 6 months after diagnosis or first referral to RDN, and determine if additional sessions are needed. At a minimum, the RDN should provide one annual MNT follow-up session.² For example, children and adolescents often require MNT changes because of growth or other lifestyle factors. People with type 2 diabetes often require the addition of or changes in medication. The RDN can also assist physicians and other health-care providers by helping people with diabetes understand and accept the reasons for management changes.

Types of Nutrition Therapy Interventions

In reported studies, several types of nutrition therapy interventions were used including reduced calorie/fat intake, healthy food choices, exchange lists, carbohydrate choices emphasizing carbohydrate consistency, and carbohydrate counting with insulin-to-carbohydrate ratios.²,²⁰ The primary approaches used with type 2 diabetes are reduced calorie/fat intake, healthy food choices, and carbohydrate choices, and the primary approach used with type 1 diabetes is carbohydrate counting with insulin-to-carbohydrate ratios. Selection of an approach is very individualized and should be based on personal and cultural preferences, health numeracy and literacy, and the individual’s readiness, willingness, and ability to change. The person with diabetes should be involved in choosing and individualizing the nutrition intervention that works best for them and that can achieve successful outcomes.

Other Interventions Combined with Nutrition Therapy

Diabetes Self-Management Education and Support

A recent systematic review of diabetes self-management education (DSME) for adults with type 2 diabetes demonstrated that engagement in DSME results in a statistically significant decrease in A1C levels.²¹ The report included 118 interventions with 61.9% reporting significant changes in A1C. Overall, mean reduction in A1C was 0.74% for intervention and 0.17% for control groups. A combination of group and individual encounters resulted in the largest decreases in A1C (0.88%). Contact hours >10 were associated with a greater proportion of interventions with significant reduction in A1C (70.3%). In individuals with worsening glycemic control (A1C >9%), a greater proportion of studies (83.9%) reported statistically significant reduction in A1C. These results suggest that the mode of delivery, hours of engagement, and baseline A1C all affect the degree of statistical significance and meaningful improvement in A1C.²¹

Lifestyle Interventions for Weight Loss (Nutrition Therapy, Behavioral Strategies, and Physical Activity)

Lifestyle interventions for weight loss in people with type 2 diabetes include a combination of interventions including nutrition therapy, behavioral strategies, and physical activity. A systematic review of weight-loss intervention studies reporting outcomes in overweight and obese adults with type 2 diabetes was published in September 2015.²² Seventeen study groups reviewed reported weight loss <5% of initial weight. Meta-analyses reported nonsignificant beneficial effects on A1C, lipids, and/or blood pressure. Two study groups reported a weight loss of >5%: a Mediterranean-style eating pattern used in newly diagnosed persons with type 2 diabetes and an intensive lifestyle intervention used in the Look AHEAD trial. Both studies incorporated physical activity and involved frequent contact with health-care providers. They reported significant improvements in A1C, lipids, and blood pressure. Therefore, weight loss of >5 % appears necessary in order to improve metabolic outcomes. To achieve weight loss >5%, combined interventions of nutrition (including a healthy eating pattern and energy restriction), behavioral strategies, regular physical activity, and frequent contact with health-care professionals for support are important and should be used as the primary treatment strategy.²²

SUMMARY OF NUTRITION THERAPY AND HEALTHY EATING INTERVENTIONS

• Medical nutrition therapy is effective for diabetes management.

• Nutrition education and counseling is best provided in a series of encounters—usually one initial encounter with two or three follow-up encounters, which can be implemented individually or in groups. The RDN should determine if and when additional encounters are needed. Ongoing nutrition education counseling is needed yearly, or more often as required or requested, or when changes in medication are made. Weight loss is important for most people with prediabetes and those initially diagnosed with type 2 diabetes.

• For individuals with long-standing type 2 diabetes, attention to healthy eating using a variety of eating patterns can be important for improving the quality of food choices and clinical outcomes. For people with type 2 diabetes, the focus should be on improving the quality of the food choices by incorporating more nutrient-dense foods and reducing energy intake.

• For individuals with type 1 diabetes, matching insulin doses to planned carbohydrate intake is most important for the management of diabetes.

• A variety of healthy eating patterns and nutrition therapy interventions can be implemented depending on which are best suited to the needs of the individual with diabetes.

• Self-monitoring blood of glucose patterns and A1C results can be used to evaluate the effectiveness of MNT and can be used to improve glycemic outcomes; lipids and blood pressure outcomes also require monitoring and evaluation.

• Selecting the most appropriate eating pattern and nutrition intervention involves individual goal setting with the person with diabetes and includes use of educational and behavioral tools and strategies tailored to each person with diabetes.

BIBLIOGRAPHY

1. Bantle JP, Laine DC, Castle GW, et al. Postprandial glucose and insulin responses to meals containing different carbohydrates in normal and diabetic subjects. N Engl J Med 1983;309:7–12

2. Academy of Nutrition and Dietetics. Diabetes type 1 and 2 evidence-based nutrition practice guideline for adults, 2015. Academy of Nutrition and Dietetics Evidence Analysis Library. Available from http://www.andeal.org/topic.cfm?menu=5305. Accessed September 2016

3. Evert AB, Boucher JL, Cypress M, et al. Nutrition therapy recommendations for the management of adults with diabetes. Diabetes Care 2013;36:3821–3842

4. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Nutrition therapy. Can J Diabetes 2013;37:S45–55

5. Dyson PA, Kellly T, Deakin T, et al. Diabetes UK evidence-based nutrition guidelines for the prevention and management of diabetes. Diabet Med 2011;28:1282–1288

6. Daly A, Michael P, Johnson EQ, et al. Diabetes white paper: defining the delivery of nutrition services in Medicare medical nutrition therapy vs. Medicare diabetes self-management training programs. J Am Diet Assoc 2009;109:528–539

7. Writing Group of the Nutrition Care Process/Standardized Language Committee. Nutrition care process and model part I: the 2008 update. J Am Diet Assoc 2008;208:1113–1117

8. Maryniuk M. Healthy Eating. AADE Practice Synopsis. American Association of Diabetes Educators. 2015. Available from http://www.diabeteseducator.org. Accessed September 2016

9. Pastors JG, Franz MJ. Effectiveness of medical nutrition therapy in diabetes. In American Diabetes Association Guide to Nutrition Therapy for Diabetes. 2nd ed. Franz MJ, Evert AB, Eds. American Diabetes Association, Alexandria, VA, 2012

10. Ajala O, English P, Pinkney J. Systematic review and meta-analysis of different dietary approaches to the management of type 2 diabetes. Am J Clin Nutr 2013;7:505–516

11. Franz M, Boucher JL, Evert AB. Evidence-based diabetes nutrition therapy recommendations are effective: the key is individualization. Diabetes Metab Syndr Obes: 2014;7:65–72

12. Wheeler ML, Dunbar SA, Jaacks LM, et al. Macronutrients, food groups, and eating patterns in the management of diabetes: a systematic review of the literature, 2010. Diabetes Care 2012;35:434–445

13. Ley SH, Hamdy O, Mohan V, Hu FB. Prevention and management of type 2 diabetes: dietary components and nutritional strategies. Lancet 2014;383:1999–2007

14. Salmeron J, Hu FB, Manson JE, et al. Dietary fat intake and risk of type 2 diabetes in women. Am J Cl Nutr 2001;73:1019–1026

15. Hu FB, van Dam RM, Liu S. Diet and risk of type II diabetes: the role of types of fat and carbohydrate. Diabetologia 2001;44:805–817

16. Schulze MB, Schulz M, Heidemann C, et al. Fiber and magnesium intake and incidence of type 2 diabetes: a prospective study and meta-analysis. Arch Intern Med 2007;167:956–965

17. Bhupathiraju SN, Tobias DK, Malik VS, et al. Glycemic index, glycemic load, and risk of type 2 diabetes: results from 3 large US cohorts and an updated meta-analysis. Am J Clin Nutr 2014;100:218–232. doi:10:3945/ajcn.113.079533

18. UKPDS Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS22). UK Prospective Study (UKPDS) Group. Lancet 1998;352:837–853

19. Coppell KJ, Kataoka M, Williams SM, et al. Nutritional intervention in patients with type 2 diabetes who are hyperglycemic despite optimized drug treatment— Lifestyle Over and Above Drugs in Diabetes (LOADD) study: randomized controlled trial. BMJ 2010;341:c3337. doi. 10.1136/bmj.c337

20. Franz MJ, Powers MA, Leontos C, et al. The evidence for medical nutrition therapy for type 1 and type 2 diabetes in adults. J Am Diet Assoc 2010:110:1852–1889

21. Chrvala CA, Sherr D, Lipman RD. Diabetes self-management education for adults with type 2 diabetes mellitus: A systematic review of the effect on glycemic control. Patient Edu Couns 2015;99:926–943. doi. 10.1016/j.pec.2015.11.003

22. Franz MJ, Boucher JL, Rutten-Ramos S, VanWormer JJ. Lifestyle weight-loss intervention outcomes in overweight and obese adults with type 2 diabetes: a systematic review and meta-analysis of randomized clinical trials. J Acad of Nutr and Diet 2015;115:1447–1463

Joyce Green Pastors, MS, RDN, CDE, is an Assistant Professor of Education, Internal Medicine, Director of the Virginia Center for Diabetes Prevention and Education, University of Virginia Health System, Charlottesville, VA.

Chapter 2: Macronutrients and Nutrition Therapy for Diabetes

Janice S. MacLeod, MA, RDN, CDE

Marion J. Franz, MS, RDN, CDE

Highlights

Macronutrient Distribution for Diabetes Nutrition Therapy

Carbohydrate and Diabetes Nutrition Therapy

Protein and Diabetes Nutrition Therapy

Fat and Diabetes Nutrition Therapy

Summary of Recommendations for Macronutrients

HIGHLIGHTS

MACRONUTRIENTS AND NUTRITION THERAPY FOR DIABETES

• No ideal distribution of macronutrients—carbohydrate, protein, and fat—for diabetes nutrition therapy has been identified. The key is individualization of the nutrition therapy intervention, taking into account treatment goals, personal preferences, and the individual’s ability and willingness to make lifestyle changes. As for all Americans, a healthy eating pattern is recommended for people with diabetes, emphasizing a variety of nutrient-dense foods in appropriate portion sizes for optimal energy intake.

• Because of beneficial effects and/or similarities in outcomes, it would seem prudent to recommend an eating plan with moderate amounts of carbohydrate (which is how many people with diabetes already eat), that is low in saturated fats, and that includes fruits, vegetables, whole grains, and low-fat dairy foods in appropriate amounts and portion sizes. The amount of carbohydrate eaten and available insulin are important factors influencing postprandial glycemic response and are vital considerations when determining an appropriate eating plan for an individual with diabetes.

• While sucrose-containing foods can be substituted for other carbohydrates in the eating plan, just as for the general population added sugars should not exceed 10% of total calories per day. Sugar-sweetened beverages should be limited or avoided to reduce the risk of weight gain and worsening of cardiometabolic risk profiles.

• In people with type 2 diabetes, ingestion of protein does not increase postprandial glucose or lipid responses but does cause an acute insulin response. This response does not result in a long-term effect on insulin levels. Carbohydrate sources containing protein should not be used to treat or prevent hypoglycemia. In type 1 diabetes, very large protein loads (above usual intake) may require additional insulin for coverage.

• Consumption of saturated fat and trans fatty acids is associated with an adverse effect on lipid/lipoprotein profiles and increased risk of cardiovascular disease. It is recommended for people with diabetes, as with the general population, that saturated fats be limited to less than 10% of calories, that saturated fats be replaced with unsaturated fats, and that intake of trans fat be minimized. Ingestion of omega-3 fatty acids from fish is recommended. Individuals with diabetes and dyslipidemia may additionally benefit from consuming 1.6–3.0 g of plant stanols or sterols found in enriched foods.

Macronutrients and Nutrition Therapy for Diabetes

The appropriate implementation of nutrition therapy is critical to achieving positive outcomes in the management of type 1 and type 2 diabetes. Just as there is no one medication regimen appropriate for all, so there is no one nutrition therapy prescription appropriate for all people with diabetes. Instead, as reviewed in Chapter 1, a variety of nutrition therapy interventions lead to improved outcomes. It is important that health-care professionals collaborate with the individual and/or significant others they are counseling to determine effective nutrition therapy interventions that can be individualized to the person’s metabolic goals and that he/she is willing and able to implement. Through ongoing evaluation to assess efficacy, the intervention(s) should be adjusted as needed to assure that positive outcomes are achieved.

The primary goals of nutrition therapy for diabetes are to improve glycemic, lipid, and blood pressure targets and to achieve and maintain body weight goals, thus contributing to reduced risk for potential long-term complications of diabetes and heart disease and improving the quality of life for individuals with diabetes.¹ How best to achieve these goals has been a topic of considerable discussion and ongoing research. The Academy of Nutrition and Dietetics (the Academy) published Evidence-Based Nutrition Practice Guidelines (EBNPG) for adults with type 1 and type 2 diabetes in the Evidence Analysis Library (EAL) in 2008, followed by evidence-based nutrition recommendations.² The Academy recently published updated evidence-based nutrition guidelines and recommendations for diabetes.³ In 2013, the American Diabetes Association published a position statement titled Nutrition Therapy Recommendations for the Management of Adults with Diabetes.¹ These recommendations are integrated into the Association’s annual Standards of Medical Care in Diabetes and are updated as new evidence becomes available.⁴

This chapter reviews and summarizes macronutrient (carbohydrate, protein, and fat) evidence from the 2012 American Diabetes Association Guide to Nutrition Therapy for Diabetes, 2nd Edition,⁵ incorporates research published after 1 March 2011, and summarizes key recommendations related to the role of macronutrients in nutrition therapy for diabetes. To answer the key question—What are the roles of carbohydrate, protein, and fat in diabetes management?—a literature search was conducted using PubMed MEDLINE, and additional articles were identified from reference lists. Search criteria included the following: carbohydrate, protein, fat, macronutrients, research in human subjects with diabetes, and English language articles. Study inclusion criteria included: randomized clinical trials (RCT) and prospective observational studies, subjects with diabetes, 10 subjects in each study arm, no single test meals. The initial search produced 62 articles, of which 45 were excluded because titles or abstracts did not meet inclusion criteria. Seventeen articles were retrieved for more detailed evaluation. Six of these articles are included and two were added from the review of reference lists, making a total of eight studies (six clinical trials and two observational studies) that met inclusion criteria. These studies are summarized in Table 2.1. Evidence published before 1 March 2011 is included in the tables in Chapter 2: Macronutrients and Nutrition Therapy for Diabetes in the previous edition of this book,⁵ and in the article by Franz et al., The Evidence for Medical Nutrition Therapy for Type 1 and Type 2 Diabetes in Adults.² Evidence from the Scientific Report of the 2015 Dietary Guidelines Advisory Committee⁶ is also referenced.

Table 2.1 Macronutrient (Carbohydrate, Protein, and Fat) Research

T2D, type 2 diabetes; LFD, low-fat diet; CHO, carbohydrate; LCD, low-carbohydrate diet; NS, nonsignificant; A1C, hemoglobin A1c; HDL-C, high-density lipoprotein cholesterol; SS, statistically significant; RCT, randomized controlled trial; PRO, protein; SFA, saturated fatty acids; LCalD, low-calorie diet; LCKD, low-carbohydrate ketogenic diet; BMI, body mass index; WC, waist circumference; BG, blood glucose; FPG, fasting plasma glucose; BP, blood pressure; TG, triglycerides; db, diabetes; TC, total cholesterol; VLC, very low–carbohydrate; HC, high carbohydrate; UFA, unsaturated fatty acids; LDL-C, low-density lipoprotein cholesterol; NA, not applicable; CRP, C-reactive protein; PUFA, polyunsaturated fatty acid; MUFA, monounsaturated fatty acid; GI, glycemic index; kj, kilojoules (1 kcal = 4.184 kj).

MACRONUTRIENT DISTRIBUTION FOR DIABETES NUTRITION THERAPY

The American Diabetes Association’s 2013 nutrition position statement concluded that based on reviewed evidence, it is unlikely that there is an optimal mix of macronutrients for all people with diabetes; therefore, macronutrient distribution should be based on individualized assessment of current eating patterns, preferences, and metabolic goals.¹ For guidance on macronutrient distribution, the Institute of Medicine’s (now the Health and Medicine Division of the National Academies of Medicine) dietary reference intakes (DRIs) for a healthy eating pattern for adults may be helpful.¹⁸ The DRIs acceptable macronutrient distribution ranges for macronutrients as a percentage of total energy are as follows: carbohydrate (45–65%), fat (20–35%), and protein (10–35%). The position statement also notes that regardless of the macronutrient distribution, total energy intake must be appropriate for weight management. The mix of macronutrients and the individualized eating plan should be collaboratively developed to meet the metabolic goals and individual preferences of the person with diabetes.¹,⁴

A 2012 American Diabetes Association systematic review of the literature regarding macronutrients, food groups, and eating patterns in the management of diabetes concluded that several different macronutrient distributions may lead to improvement in glycemic and/or cardiovascular disease (CVD) risk factors and that different approaches to medical nutrition therapy and eating patterns effectively improve glycemic control and reduce cardiovascular risk among individuals with diabetes.¹⁹

A 2013 systematic review and meta-analysis of different dietary approaches to the management of type 2 diabetes concluded there may be a range of beneficial dietary options for people with type 2 diabetes.²⁰ Low-carbohydrate (13–45% of daily energy), low–glycemic index (GI), Mediterranean-style, and high-protein (26.5–30% of calories) diets were effective in improving various markers of cardiovascular risk in people with diabetes, with the largest improvement in glucose management seen with the Mediterranean approaches (35–55% of calories as carbohydrate).

The Academy of Nutrition and Dietetics’ EBNPG reviewed a total of 11 studies using differing percentages of carbohydrate, fat, and/or protein and concluded that research does not support an ideal percentage of energy from macronutrients in the eating plan for people with diabetes. It is recommended that registered dietitian nutritionists (RDNs) encourage consumption of macronutrients on the basis of the DRIs and collaborate with the client in developing an individualized healthy eating pattern that meets the glycemic and metabolic goals of the individual.³

The Scientific Report of the 2015 Dietary Guidelines for Americans Advisory Committee encourages identification of healthy eating patterns (Healthy U.S.-style Pattern, the Healthy Mediterranean-style Pattern, and the Healthy Vegetarian Pattern) that are not a rigid prescription, but rather include options that can accommodate cultural, ethnic, traditional, and personal preferences as well as food costs and availability.⁶ Though diverse, healthy patterns share key elements: a higher intake of vegetables and fruits, an emphasis on whole grains, low- or non-fat dairy, seafood, legumes, and nuts; moderate in alcohol (among adults); and low in sugar-sweetened foods and drinks and refined grains. Eating patterns should be low in saturated fat, added sugars, and sodium with sources of saturated fat replaced with unsaturated fat (particularly polyunsaturated fatty acid [PUFA]) and sugars reduced and replaced with healthy options (such as water in place of sugar-sweetened beverages). Strong evidence shows that it is not necessary to eliminate food groups or adhere to a single dietary pattern to achieve a healthy pattern of eating. For guidelines and more information on healthy eating patterns reference Chapter 3: Eating Patterns for the Management of Diabetes.

CARBOHYDRATE AND DIABETES NUTRITION THERAPY

Carbohydrate consists of sugars, starches, and fiber. Along with the acceptable macronutrient distribution ranges, the DRIs set a recommended dietary allowance (RDA) for carbohydrate of at least 130 g/day for adults and children.¹⁸ This RDA is based on the estimated average requirement for carbohydrate ingestion that will provide the brain with adequate glucose without use of additional glucose from protein or triglycerides stored in the fat cells (100 g/day stored) and a coefficient of variation use of 15% based on the variation in brain glucose utilization. The RDA is equal to the estimated average requirement (100 g/day) plus twice the coefficient of variation to cover the needs of nearly all (97–98%) healthy individuals in a particular life stage (or 15% × 2). Therefore, the RDA for carbohydrate is at least 130% of the estimated average requirement, or at least 130 g/day of carbohydrate.

Definitions of carbohydrate intake have not been consistently articulated. A high carbohydrate intake is often defined as a carbohydrate intake ≥55% of total energy. A low carbohydrate intake may be defined as <25% of total energy or <130 g/day. A very low–carbohydrate ketogenic diet is defined as <20 g of carbohydrate per day. However, definitions for carbohydrate intake vary. For example, one meta-analysis used 9–45% of total energy as carbohydrate as a definition of low-carbohydrate intake.²¹ As a result of this definition, there was an overlap of carbohydrate intake in the low- and high-carbohydrate groups (carbohydrate in the high-carbohydrate group ranged from 40–70%). Of interest is a Mediterranean-style eating pattern in subjects with type 2 diabetes that was considered to be low carbohydrate, with <50% of daily calories from carbohydrate (actual intake ~44%),²² whereas for most individuals with type 2 diabetes, this intake of carbohydrate would be considered a moderate-carbohydrate intake. A systematic review and meta-analysis included 20 studies of different dietary approaches and patterns, which ranged from 13–75% of energy from carbohydrate in actual subject intake in the management of type 2 diabetes.²⁰

It is important to note that most individuals with diabetes do not eat a low- or high-carbohydrate diet, but rather report a moderate intake; studies reported an intake of ~46% in individuals with type 1 diabetes,²³ 44% in individuals with type 2 diabetes,²⁴ and ~48% in youth with type 1 and type 2 diabetes.²⁵ Furthermore, it appears difficult for people with type 2 diabetes to eat a high-carbohydrate diet. In the U.K. Prospective Diabetes Study, despite receiving individual education from dietitians on the recommended carbohydrate intake of 50–55%, people with diabetes reported a carbohydrate intake of 43% energy intake, which was similar to the general public.²⁶ Based on data from the National Health and Nutrition Examination Survey (NHANES) food frequency surveys of respondents with diabetes, it is estimated that people with diabetes eat approximately 36–40% of calories from fat and about 16–18% of calories from protein.²⁷

Carbohydrate and Glycemia

The balance between digestible carbohydrate and available insulin is a major determinant of postprandial glucose levels. However, other intrinsic and extrinsic variables also influence the effect of carbohydrate on glucose levels. Continuous glucose monitoring systems can be used to better understand the postprandial effects of carbohydrate. Under debate is what amount of carbohydrate intake best facilitates blood glucose management in people with diabetes. The Academy of Nutrition and Dietetics 2015 EAL concluded that limited research regarding differing amounts of carbohydrate (39–57% of energy) and fat (27–40% of energy) reported no significant effects on A1C or insulin levels in adults with diabetes, independent of weight loss.³ The American Diabetes Association nutrition therapy recommendations note that monitoring carbohydrate intake, whether by carbohydrate counting or experience-based estimation, remains a key strategy in achieving glycemic goals.¹,⁴

Carbohydrate and Insulin Responses

A review compared short-term intervention studies with higher (>50% of total energy) versus lower carbohydrate intake in subjects with and without diabetes.²⁸ Of 11 studies in subjects without diabetes, 7 reported an increase in insulin sensitivity from the higher-carbohydrate diet and 5 reported no differences. Of eight studies in subjects with diabetes, five reported improvements in insulin sensitivity from the higher-carbohydrate diet and three reported no difference. The author concluded that higher-carbohydrate diets do not adversely affect insulin sensitivity and may offer some benefits on insulin sensitivity. Longer-term clinical trials and epidemiological studies in people without diabetes have also reported no adverse effects on insulin sensitivity from higher-carbohydrate diets.¹⁰,²⁹,³⁰

The Academy’s 2015 EAL identified two randomized controlled trials³¹,³² regarding the relationship of differing amounts of carbohydrate (39–57% of energy), independent of weight loss, on endogenous or exogenous insulin levels in adults with well-managed type 1 and type 2 diabetes.³ Both reported no significant effect on insulin levels. Strychar et al. reported no significant impact of variations in amount of carbohydrate intake levels on exogenous insulin levels in adults with well-managed type 1 diabetes.³¹ Wolever et al. reported no significant impact of variations in amount of carbohydrate intake on endogenous insulin levels in adults with well-managed type 2 diabetes.³²

Examining the effect of carbohydrate on insulin action is difficult because any change in one component of the eating pattern is accompanied by changes in other components of the eating pattern. Therefore, as carbohydrate intake is increased, fat is generally decreased, and vice versa. Chronic consumption of foods high in fat, especially saturated fats, as will be reviewed later, is reported to increase insulin resistance.

Type 1 Diabetes

In people receiving intensive treatment in the Diabetes Control and Complications Trial, a lower carbohydrate (37%) intake and higher total fat (45%) and saturated (17%) fat intakes were associated with worse glycemic outcomes at year 5 compared to a higher carbohydrate (56%) intake (A1C values of 7.5% versus 7.0%, respectively), independent of exercise and BMI.²³ The authors suggest that the total carbohydrate content consumed is less critical than the total fat and saturated fat content consumed, to which it is usually inversely related. They note that high-fat meals have been shown to interfere with indexes of insulin signaling, which results in a transient increase in insulin resistance,³³ and that a lower-fat diet reduces basal free fatty acid concentrations and improves peripheral insulin sensitivity in type 1 diabetes.³⁴

A systematic review studied the effects of fat, protein, and glycemic index on acute postprandial glucose (as measured by CGM) in adults and children with type 1 diabetes and concluded that very high–fat/protein meals require more insulin than lower-fat/protein meals with identical carbohydrate content.³⁵ However, the meals usually consumed contain moderate amounts of protein and fat, which is assumed to be covered by the usual basal and bolus insulin doses.³⁶ Glycemic responses to excessive amounts of protein and fat vary greatly and research at this time does not provide guidelines for insulin adjustments.

To determine the effects on CVD risk factors in people with type 1 diabetes, a eucaloric diet higher in carbohydrate and lower in fat was compared to a diet lower in carbohydrate and higher in monounsaturated fatty acids (MUFAs).³⁷ After 6 months, there were no significant differences between groups other than decreased plasminogen activator inhibitor-1 and weight gain in the lower-carbohydrate/higher-MUFA group. This result suggests that if individuals choose to lower carbohydrate intake, these calories should be replaced with unsaturated fats rather than saturated fats and special attention should be paid to total energy intake.

Type 2 Diabetes

Clinical trials in individuals with type 2 diabetes have compared lower carbohydrate intakes and higher total fat and saturated fat intakes to higher carbohydrate intakes and lower total fat and saturated fat intakes. A recently published 1-year study compared the effects of a very low–carbohydrate (14% carbohydrate), high–unsaturated fat, low–saturated fat diet with a eucaloric high-carbohydrate (53% carbohydrate), low-fat diet on glycemic control and cardiovascular risk factors in obese type 2 diabetes subjects.¹¹ Both diets achieved substantial weight loss and reduced A1C and fasting glucose. The low-carbohydrate diet achieved greater reductions in triglycerides and increases in HDL cholesterol, decreased blood glucose variability, and decreased diabetes medication requirements. Of note is that in both arms of the trial, saturated fat was held to <10% and that both arms saw similar reductions in LDL cholesterol.

In a prospective randomized parallel trial, adult subjects with average duration of type 2 diabetes of 8.8 years and at risk for cardiovascular disease were randomized to a low-fat diet (55–60% carbohydrate) or low–carbohydrate diet (20% carbohydrate) for 2 years.⁷ A1C was reduced significantly, HDL was raised significantly, and insulin doses were reduced significantly more with the low-carbohydrate diet at 6 months when dietary adherence was good. However, at study end (12 months), when differences in macronutrient intake between the 2 groups were minimal and treatment differences had disappeared, both groups achieved a similar significant weight loss. In a secondary analysis of data from the Early ACTivity in Diabetes randomized controlled trial, in which participants were enrolled in a nonprescriptive dietary intervention for 6 months, clinically important metabolic improvements observed were not explained by changes in macronutrients in reported food and beverage intake throughout the study.¹⁰ In a study of 363 obese subjects, subjects chose to follow a low-calorie or low-carbohydrate (ketogenic) diet [LCKD] for 24 weeks. Subjects with diabetes (n = 102) following the LCKD diet showed a significant positive effect on body weight, lipids, and glycemia, including a significant reduction in anti-hyperglycemic medications relative to the other groups.⁸ Similar results were seen in a smaller (n = 24) trial of 6 months comparing a non–caloric restricted, low-carbohydrate diet (70–130 g/day) to a calorie-restricted diet in Japanese subjects with poorly managed type 2 diabetes.⁹ Subjects on the low-carbohydrate diet experienced significant improvements in metabolic status relative to the calorie-restricted diet.

Three earlier 1-year studies in people with type 2 diabetes comparing higher-carbohydrate diets to lower-carbohydrate, low-fat, or high-MUFA diets reported no differences in A1C, weight loss, LDL cholesterol, triglycerides, or blood pressure.³²,³⁷,³⁸ A vegetarian diet (52% energy from carbohydrate) was compared to a diet high in MUFAs, with reported beneficial effects from the vegetarian diet on lipids (total cholesterol, LDL cholesterol, postprandial triglycerides), glucose, and insulin levels.³⁹

A recent review critically examined the research on the effectiveness of low-carbohydrate diets (LCD) in persons with type 2 diabetes.⁴⁰ The review identified nine previous meta-analyses incorporating 153 studies, which produced inconsistent findings. Five of the meta-analyses reported improved blood glucose management with LCD and four reported no difference between LCD and higher-carbohydrate diets on blood glucose management. To improve the quality of the studies analyzed, the following criteria were applied: randomized controlled trials ≥4 weeks in people >18 years with type 2 diabetes; a carbohydrate intake ≤45% of total energy intake; and a dietary intake assessment at the end of the study. Twelve studies met inclusion criteria. There were no significant differences in metabolic markers, including blood glucose management, between the two diets. Carbohydrate intake at 1 year in very LCD (<50 g of carbohydrate/day) ranged from 132–162 g/day. In some studies the difference between diets was as little as 8 g/day of carbohydrate. They concluded that a LCD appears no different from a high-carbohydrate diet in terms of metabolic markers and glycemic control. Very LCDs may not be sustainable over the long term as carbohydrate intake converges toward a moderate level. They also note that the variable quality of studies in earlier meta-analyses likely explains the inconsistent findings between meta-analyses.

Another recent study examined the associations of different proportions of carbohydrates and fat in reported dietary intake—within the ranges recommended by different guidelines—with metabolic risk factors.¹³ Eating habits of people with type 2 diabetes (n = 1,785) enrolled in the TOSCA.IT study were assessed using a food frequency questionnaire. Results revealed that increasing carbohydrate intake from <45% to ≥60% is associated with significantly lower A1C, triglycerides, and C-reactive protein (CRP) (P < 0.05). A fiber intake ≥15 g/1000 kcal was associated with better lipids and lower A1C and CRP than a lower fiber intake. An added-sugars intake of ≥10% energy intake was associated with adverse lipids and higher CRP than lower intake. Furthermore, increasing fat intake from <25% to ≥35% was associated with a significant increase in A1C, LDL cholesterol, triglycerides, and CRP. Thus, increasing the proportion of carbohydrate of the eating pattern within the relatively narrow proposed ranges is associated with significant improvements in the metabolic profile and low-grade inflammation.

In summary, it appears likely that the total energy intake of the eating pattern outweighs the distribution of carbohydrates in terms of importance. High-carbohydrate diets, which are generally low in fat and low in saturated fat, tend to have beneficial effects on total and LDL cholesterol, whereas low-carbohydrate diets tend to have beneficial effects on triglycerides and HDL cholesterol. Because of beneficial and/or similar lipid outcomes, it would seem prudent to recommend an eating pattern with moderate amounts of carbohydrate (which is how many people with diabetes already eat) that is low in saturated fats, and that includes fruits, vegetables, whole grains, and low-fat dairy foods in appropriate amounts and portion sizes.

Types of Carbohydrate

Sucrose

After reviewing three studies in which sucrose was substituted for isocaloric amounts of starch, the Academy EAL concluded that consumption of nutritive sweeteners (such as sucrose and isomaltulose) in an isocaloric diet has no significant effect on A1C, exogenous or endogenous insulin levels, or on HDL-C levels in adults with diabetes.³ Mixed results were seen regarding the impact of consuming nutritive sweeteners on total cholesterol, LDL-C, and triglycerides. Based on these results, the American Diabetes Association concluded, 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.¹ The Dietary Guidelines Advisory Committee (DGAC) recommends a maximal intake level of ≤10% of total energy from added sugars.⁶ For a daily energy intake of ~2,000 kcal, this would be about 12 teaspoons of added sugars; however, average intake for all individuals in the U.S. is ~16 teaspoons per day (268 kcal or 13.4% total calories). (As a frame of reference, one 12-ounce can of cola contains ~8 teaspoons of added sugar, for ~130 kcal.) The American Heart Association recommends that most women should eat or drink no more than 100 kcal/day from added sugars and most men no more than 150 kcal/day.⁴¹

Fructose

Free fructose refers to the monosaccharide fructose that is naturally occurring in fruits and does not include the fructose found in either high-fructose corn syrup or the disaccharide sucrose. The American Diabetes Association concluded that [free fructose] consumption is not more deleterious than other forms of sugar unless intake exceeds approximately 12% of total caloric intake.¹ Agave nectar is an example of a food containing large amounts of free fructose that is marketed to people with diabetes. Individuals should be advised to avoid excessive consumption of agave nectar and similar foods. The American Diabetes Association further noted that glucose in the form of tablets, liquid, or gels may be the preferred treatment over fruit juice in the correction of low blood glucose levels.

High-Fructose Corn Syrup

High-fructose corn syrup is composed of either 42% or 55% fructose and is similar in composition to table sugar (sucrose). There is considerable evidence among individuals without diabetes that large quantities of sugar-sweetened beverages (SSBs)—which contain high amounts of carbohydrate such as sucrose or high-fructose corn syrup—should be avoided to reduce the risk for weight gain and exacerbation of cardiometabolic risk factors including selective deposition of ectopic and visceral fat, lipid metabolism, blood pressure, insulin sensitivity, and de novo lipogenesis. Glucose-sweetened beverages are not reported to have similar negative effects. While research is not available among individuals with diabetes, there is little reason to suspect that the diabetes state would mitigate the adverse effects of SSBs.¹

In a systematic review and meta-analysis examining the prospective associations between consumption of SSBs, artificially sweetened (also known as non-nutritive sweeteners or low-calorie sweeteners) beverages, and fruit juice in type 2 diabetes, researchers concluded that habitual consumption of SSBs was associated with a greater incidence of type 2 diabetes independent of adiposity, and that artificially sweetened beverages and fruit juice were unlikely to be healthy alternatives to SSBs for the prevention of type 2 diabetes.⁴²

According to the Scientific Report of the 2015 Dietary Guidelines Advisory Committee, beverages contribute 19% of total energy intake, with sugar-sweetened beverages contributing 35%, milk and milk drinks 26%, and 100% fruit juices contributing 10% of this.⁶ DGAC recommends that individuals drink water when thirsty and not substitute fruit juices or artificially sweetened beverages for SSBs.

Fiber and Whole Grains

Foods containing fiber and whole grains are recommended. After reviewing two studies reporting on the effect of fiber intake on glycemic and lipid outcomes in individuals with diabetes, the Academy EAL concluded that individuals with diabetes should be encouraged to consume dietary fiber from foods such as fruits, vegetables, whole grains, and legumes at the levels recommended by the DRIs(21–25 g/day for adult women and 30–38 g/day for adult men, depending on age) or U.S. Department of Agriculture (14 g fiber/1,000 kcal), due to the overall health benefits of dietary fiber.³ Limited research regarding differing amounts of fiber intake from foods, independent of weight loss, reported mixed results on A1C and lipids and no significant effects on exogenous insulin levels.

While diets containing 44–50 g fiber daily are reported to improve glycemia in persons with diabetes, more usual intakes (up to 24 g/day) have not shown beneficial effects on glycemia.⁴³ The American Diabetes Association’s systematic review concluded that while consuming whole grains was not associated with improving blood glucose in type 2 diabetes, it potentially leads to reductions in systemic inflammation.¹⁹ The Association recommends that people with diabetes consume at least the amount of fiber and whole grains recommended for the general public.¹

Consumption of whole-grain foods is likely to be of equal importance in reducing CVD risk as fiber. Whole-grain foods contain fiber, vitamins, minerals, phenolic compounds, phytoestrogens, and other unmeasured constituents, which have been shown to lower serum lipids and blood pressure, improve glucose and insulin metabolism and endothelial function, and alleviate oxidative stress and inflammation in the general population.⁴⁴ In the Nurses’ Health Study, a prospective study of 7,822 women with type 2 diabetes, intakes of whole grains, cereal fiber, and bran were inversely associated with all-cause and CVD mortality during a 26-year follow-up.⁴⁴ Bran intake had the strongest association, and grain germ intake, which was also evaluated, was not associated with all-cause or CVD mortality.

Glycemic Index/Glycemic Load

The glycemic index (GI) measures the relative area under the glucose curve of 50 g digestible carbohydrate compared with 50 g of a standard food, either glucose or white bread. The GI measures how rapidly blood glucose levels increase after eating different types of carbohydrate-containing foods, which implies that a high-GI food peaks quickly and a low-GI food peaks later. In a review of studies comparing different types of low- and high-GI foods and glucose in people without diabetes, glucose peaks occurred consistently at ~30 minutes, regardless of whether the food was categorized as low-, medium-, or high-GI, with a modest difference in glucose peak values between high- and low-GI foods.⁴⁵ In contrast to what is often stated, low-GI foods did not produce a slower rise in blood glucose, nor did they produce an extended, sustained glucose response. The estimated glycemic load (GL) of foods, meals, and eating patterns is calculated by multiplying the GI by the amount of available carbohydrate in each food and then totaling the values for all foods in a meal or eating pattern. The GL is used most often in research studies, especially in epidemiological studies, but because of the calculations needed, it is not likely a practical approach for individuals to use for planning meals or prandial insulin doses.

The American Diabetes Association’s systematic review of macronutrients, food groups, and eating patterns in the management of diabetes concluded that there is generally little difference between low-GI and high-GI diets in terms of blood glucose management or cardiovascular risk. The finding of a slight improvement in glycemia with the lower-GI diet in several of the research studies reviewed is confounded by a higher fiber intake.¹⁹ After reviewing five studies reporting on the relationship between the GI values of foods/diets and metabolic outcomes, the Academy of Nutrition and Dietetics EAL concluded the following: Studies regarding the relationship of GI, independent of weight loss, reported no significant effect on A1C, LDL-C, or blood pressure in adults with type 2 diabetes, however, the differences in GI between interventions were small. Research regarding the relationship of glycemic index on fasting blood glucose, HDL-C, triglycerides, and total cholesterol reports mixed results. No studies were identified in adults with type 1 diabetes.³ Research in this area is complicated by possible confounding dietary factors as well as definitions