| Target Population |
Body Mass Index (BMI) |
> 25 kg/m2 |
|
Type 2 Diabetes
or
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|
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|
and |
|
|
| or Waistline |
> 40"/102 cm (men)
> 35"/88 cm (women) |
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Prediabetes |
Impaired glucose tolerance (IGT)
Impaired fasting glucose (IFG) |
| |
|
| or |
|
| |
|
|
High Risk for Type 2 diabetes |
The Metabolic Syndrome (ATP III Criteria)
Family history of type 2 diabetes mellitus (DM) (first degree relative)
Confirmed diagnosis of insulin resistance (e.g., high basal insulin)
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For Asian populations (South Asian Indians, East Asians and Malays) a BMI >23 kg/m2 and a waistline >35"/90 cm in men or >31"/80 cm in women is considered.
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| Goals |
- To improve overall metabolic control while achieving gradual weight reduction and maintaining achieved weight loss
- To improve fasting and postprandial hyperglycemia in order to prevent or reduce diabetes complications.
- To improve fasting and postprandial hypertriglyceridemia as a major lipid abnormality in the target population
- To improve lipid profile including increase of high-density lipoprotein (HDL)-cholesterol and decrease of low-density lipoprotein (LDL)-cholesterol
- To improve insulin sensitivity as a major precursor of type 2 diabetes
- To improve body fat distribution and to reduce visceral fat burden
- To reduce cardiovascular risk as evidenced by improvement of endothelial function and endothelial markers
- To reduce inflammatory cytokines, and markers of inflammation and increased coagulation
- To improve blood pressure as a contributing risk factor for cardiovascular and renal complications
- To enhance thermogenesis and maintain lean body mass
- To provide a balanced meal plan of carbohydrate, protein, and fat
- To improve overall health through increased physical activity
- To prevent and treat the chronic complications of diabetes
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| General Guidelines |
- Consideration of recent consistent and strong evidence that weight reduction improves insulin sensitivity and glycemic control in type 2 diabetes and decreases the risk of developing type 2 diabetes in prediabetes and
high-risk populations. Weight reduction should be considered one of the prime objectives of any nutrition recommendations suggested to the target population. (Strength of evidence 1)
- Any meal plan modifications should first be discussed with a Registered Dietitian (RD) or a qualified healthcare provider. (Strength of evidence 4)
- Target individuals should meet with an RD for assessment and review of medical management and treatment goals to select approach for medical nutrition therapy. (Strength of evidence 2)
- The diet composition, described below, is for general guidance only and may be individualized by the RD or the healthcare provider according to clinical judgment. (See Appendix A in the original guideline document).
- Meal plans do not need to include between-meal or evening snacks. (Strength of evidence 4)
- Meal-to-meal consistency in carbohydrate is of primary importance to patients with fixed medication/insulin programs. (Strength of evidence 4)
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| Weight Reduction |
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- A structured lifestyle plan that combines dietary modification and exercise is necessary for weight reduction.
- A modest and gradual weight reduction of one pound every one to two weeks should be the optimal target. (Strength of evidence 2)
- Reduction of daily caloric intake should be by 250 to 500 calories. (Strength of evidence 4) Total daily caloric intake should not be less than 1000 to 1200 for women and 1200 to 1600 for men, or based on an RD assessment of usual intake. (Strength of evidence 4)
- Weight reduction should be individualized and continued until BMI reaches the normal range (18.5 to 25 kg/m2) or until an agreed upon BMI goal is reached.
- Target individuals should meet with RD to learn and practice portion control as an effective way of weight control. (Strength of evidence 4)
- Meal replacements (MR) in the form of shakes, bars, ready-to-mix powders, and pre-packaged meals that match these nutrition guidelines are helpful for some patients (Strength of evidence 2). Blood glucose patterns frequently change with the initiation of meal replacements, and diabetes medications may need adjustment. Patients should be told to monitor their blood glucose carefully to identify hypoglycemia. (Strength of evidence 2)
- U.S. Food and Drug Administration (FDA)-approved weight management medications should be prescribed, if indicated. Approved medications are an adjunct to dietary and lifestyle changes (Strength of evidence 2).
- Bariatric surgeries are effective options and should be encouraged when indicated (consider in individuals with BMI >40 kg/m2 and those with BMI >35 kg/m2 with other comorbidities). (Strength of evidence 2)
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| Macronutrient Composition |
| Carbohydrate |
Percentage |
~40% of total caloric intake. (Strength of evidence 2) The total should not be less than 130 g/day. (Strength of evidence 2) |
| Glycemic Index and Glycemic |
Reduction of the quality (Glycemic Index [GI]) and quantity (Glycemic Load [GL]) of carbohydrate choices is essential for blood glucose control. The GI/GL concept is an important factor that patients should apply in their daily selection of carbohydrates foods. Foods with a low glycemic index should be selected (e.g., cereals based on oats and barley, legumes, fruits, green salad with olive oil-based dressing, and vegetables, except potatoes) |
Recommended
Not recommended
|
Vegetables and fruits (preferably fresh), legumes, whole and minimally processed grains
Refined carbohydrates or processed grains and starchy foods especially pasta, white bread, low-fiber cereal, and white potatoes should be consumed in very limited quantities (e.g., pasta ~2 oz.) (Strength of evidence 1)
|
| Fiber |
A minimum of 20 to 35 g of fiber per day is recommended. (Strength of evidence 1) If tolerated, ~50 g/day is effective in improving postprandial hyperglycemia and should be encouraged. (Strength of evidence 2) Fiber from unprocessed food, such as fresh vegetables and fruits, is preferable but, if needed, fiber supplements such as psyllium and beta-glucan can be added. (Strength of evidence 3)
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| Fat |
Percentage |
~30 to 35% of total caloric intake; (Strength of evidence 2) saturated fat should be limited to <10% of total caloric intake or <7% in individuals with LDL-cholesterol >100 mg/dL. (Strength of evidence 1) Polyunsaturated fat should comprise up to 10% of total calories, and monounsaturated fat up to 15 to 20% of total calories. |
Recommended
Not recommended
|
Mono- and polyunsaturated fats (e.g., olive oil, canola oil, nuts/seeds, and fish, particularly those high in omega-3 fatty acids). Oily fish (e.g., salmon, herring, trout, sardines, fresh tuna) 2 times/week is an ample source of omega-3 fatty acids.
Foods high in saturated fat, including beef, pork, lamb, and high-fat dairy products (e.g., cream cheese, whole milk, or yogurt) should be consumed only in small amounts.
Foods high in trans-fats (e.g., fast foods, commercially baked goods, some margarines) should be avoided. (Strength of evidence 1)
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| Cholesterol |
<300 mg/day or <200 mg/day in individuals with LDL-cholesterol >100 mg/dL. (Strength of evidence 4)
Egg yolks should be limited to 2 to 3 per week; other foods high in dietary cholesterol, such as red meat, whole-fat dairy foods, shellfish, and organ meats should be limited, as well.
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| Protein |
Percentage |
~20 to 30% of total caloric intake. (Strength of evidence 2) |
| Favorable Protein |
Fish, skinless poultry, nonfat or low-fat dairy, legumes, tofu, tempeh, and seitan. It is not recommended to increase protein from high saturated fat animal sources (e.g., beef, pork, lamb and high-fat dairy products), as it may be associated with increased cardiovascular risk. (Strength of evidence 2)
Emerging data suggest that protein aids in the sensation of fullness and that low-protein meal plans are associated with increased hunger. Thus, lean protein together with healthy fats may serve to reduce appetite and assist patients in achieving and maintaining a lower calorie level. (Strength of evidence 1) Protein also helps to maintain lean body mass during weight reduction. (Strength of evidence 2)
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| Patients with Renal Issues |
Although reducing total calories may result in a reduction of the absolute total amount of protein intake, any patient with signs of kidney disease (i.e., one or more of the following: albuminuria, proteinuria, creatinine clearance <60 mL/min) should consult a nephrologist before increasing total or percentage protein in their diet. (Strength of evidence 2) Protein intake for these patients should be modified, but not lowered to a level which may jeopardize their overall health or increase their risk for malnutrition. (Strength of evidence 4) |
| Physical Activity and Behavioral Modification |
- Physical activity, behavior modification, and good support systems are extremely important and should be included in the nutrition prescription described above. Increased physical activity, in particular, should be an integral component of any weight reduction plan to maximize the benefits of weight reduction on diabetes control and to prevent coronary and cerebral vascular disease. (Strength of evidence 1)
- A minimum of 150 to 175 minutes of moderate intensity physical activity/week should be achieved unless contraindicated. (Strength of evidence 1) A target of 60 to 90 minutes most days of the week is encouraged. (Strength of evidence 4)
- Exercise should be a mix of cardiovascular, stretching, and resistance exercises to maintain or increase lean body mass. (Strength of evidence 2)
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