General Nutrition Recommendations

Nutritional Interventions for Preventing and Managing Diabetes Complications

Physical Activity and Weight Management

To provide clinicians with clear and accessible guidelines to care for patients with diabetes mellitus

• To provide evidence-based recommendations and interventions for diabetes MNT
• To make people with diabetes and health care providers aware of beneficial nutrition interventions

Overall Objectives

• To help dietetic practitioners, patients and consumers make shared decisions about health care choices in specific clinical circumstances
• To provide evidence-based recommendations for effective MNT in the management of type 1 and type 2 diabetes in adults that assist in the normalization and maintenance of glycemia, lipid profiles, and blood pressure

Specific Objectives

• To define evidence-based diabetes nutrition recommendations for RDs that are carried out in collaboration with other health care providers
• To guide practice decisions that integrate medical, nutritional, and behavioral strategies
• To reduce variations in practice among RDs
• To promote self-management strategies that empower the adult with diabetes to take responsibility for day-to-day management
• To provide the RD with data to make recommendations to adjust MNT or recommend other therapies to achieve desired outcomes
• To enhance the quality of life for the adult with diabetes, utilizing customized strategies based on the individual's preferences, lifestyle, and goals
• To develop guidelines for interventions that have measurable clinical outcomes
• To define the highest quality of care within cost constraints of the current health care environment

Children, adolescents, and adults with or at risk of developing diabetes mellitus

Patients at risk of or diagnosed with:

• Pre-diabetes
• Type 1 diabetes
• Type 2 diabetes
• Gestational diabetes mellitus

Sub-populations, include:

• Youth with type 1 and type 2 diabetes
• Pregnant and lactating women
• Older adults with diabetes
• Individuals treated with insulin or insulin secretagogues
• Patients in a variety of settings (public health, acute care facilities, chronic care facilities)

Adults (>19 years) with type 1 or type 2 diabetes mellitus

Advanced Practice Nurses
Dietitian
Nurses
Physician Assistants
Physicians

Advanced Practice Nurses
Allied Health Personnel
Dietitians
Nurses
Physician Assistants
Physicians
Public Health Departments

Advanced Practice Nurses
Dietitians
Health Care Providers
Nurses
Pharmacists
Physician Assistants
Physicians
Students

Nutrition and Diabetes

• MNT is an essential component of any comprehensive diabetes mellitus management program (grade A).
• Meal composition affects glycemic control and cardiovascular risk (grade A).
• Tailor a diet for individual patients based on current weight, medication regimen, food preferences, lifestyle, and lipid profile (grade A).
• No specific diet is endorsed by ACE/AACE for people with diabetes mellitus (grade D).
• Total dietary carbohydrates should represent 45% to 65% of daily energy intake unless otherwise indicated (grade D).
• Protein intake should be the same as for patients who do not have diabetes mellitus: 15% to 20% of daily energy intake (grade D).
• Fiber should be consumed in amounts of 25 to 50 g/d or 15 to 25 g/1000 kcal ingested (grade A).
• Total dietary fat should generally comprise less than 30% of daily energy intake (grade D):
  • Dietary monounsaturated fatty acids and n-3 polyunsaturated fatty acids have beneficial effects on the lipid profile and should comprise most fat intake (grade B).
  • Dietary saturated fat should be limited to less than 10% of daily energy intake with less than 300 mg/d of cholesterol (grade A).
  • If the patient's LDL-C level is greater than 100 mg/dL, consumption of saturated fat should be limited to less than 7% of daily energy intake, and cholesterol should be limited to less than 200 mg/d (grade A).
  • Trans-fat intake should be minimized, or preferably, eliminated (grade D).
• Basal-bolus insulin therapy using insulin analogs or continuous subcutaneous insulin infusion in conjunction with carbohydrate counting is the most physiologic treatment and provides the greatest flexibility in terms of food choices and timing of meals (grade B).
• Basal-bolus therapy using a consistent carbohydrate meal plan can be equally effective for patients unable or unwilling to count carbohydrates (grade D).
• Instruct patients who choose to consume alcohol to limit intake to 1 drink per day for women and 2 drinks per day for men (grade D).
• Secondary prevention strategies for T2DM in individuals with impaired glucose regulation include a controlled-energy diet, exercise, and weight loss (grade A).

Clinical Considerations

All Patients With Diabetes Mellitus

Carbohydrate absorption may be altered by other foods in a mixed meal. For example, fat and fiber delay the absorption of carbohydrates and blunt the glycemic response. Terms such as simple sugars and complex carbohydrates have recently been abandoned since it is now recognized that their effects on blood glucose are similar. Sucrose does not need to be avoided by patients with diabetes mellitus, but when it is consumed, it should replace other carbohydrates in the diet.

Patients With Type 1 Diabetes Mellitus

The key to successful MNT is synchronizing carbohydrate intake with insulin therapy. The use of basal-bolus insulin therapy using insulin analogs or continuous subcutaneous insulin infusion in conjunction with carbohydrate counting is the most physiologic treatment and provides the greatest flexibility in terms of food choices and timing of meals. For patients unable or unwilling to count carbohydrates, basal-bolus therapy using a consistent carbohydrate meal plan can be equally effective. Considering the glycemic index and the glycemic load of foods is another tool that can be used to optimally time the mealtime insulin injection.

Patients With Type 2 Diabetes Mellitus

Weight control and a controlled-energy diet are essential components of diabetes mellitus management to lower glucose levels and to reduce the risk for cardiovascular disease; cardiovascular risk is lowest when the body mass index is less than 25 kg/m². Physical activity of 30 to 90 minutes per day lowers glucose levels and assists with weight loss or weight maintenance. Salt restriction to less than 1.5 g/d, in association with increased intake of fresh fruits and vegetables, is helpful in managing hypertension. If patients choose to consume alcohol, intake should be limited to 1 drink per day for women and 2 drinks per day for men.

Dietary modification to achieve target ranges for glucose, lipids, and blood pressure is a tertiary preventive strategy for the complications of diabetes mellitus.

Major Nutrition Recommendations and Interventions

Effectiveness of MNT

• Individuals who have pre-diabetes or diabetes should receive individualized MNT; such therapy is best provided by a RD familiar with the components of diabetes MNT. (B)
• Nutrition counseling should be sensitive to the personal needs, willingness to change, and ability to make changes of the individual with pre-diabetes or diabetes. (E)

Energy Balance, Overweight, and Obesity

• For patients on low-carbohydrate diets, monitor lipid profiles, renal function, and protein intake (in those with nephropathy), and adjust hypoglycemic therapy as needed. (E)

Nutrition Recommendations for the Management of Diabetes (Secondary Prevention)

Carbohydrate in Diabetes Management

• A dietary pattern that includes carbohydrate from fruits, vegetables, whole grains, legumes, and low-fat milk is encouraged for good health. (B)
• Monitoring carbohydrate, whether by carbohydrate counting, exchanges, or experienced-based estimation, remains a key strategy in achieving glycemic control. (A)
• The use of glycemic index and load may provide a modest additional benefit over that observed when total carbohydrate is considered alone. (B)
• Sucrose-containing foods can be substituted for other carbohydrates in the meal plan or, if added to the meal plan, covered with insulin or other glucose-lowering medications. Care should be taken to avoid excess energy intake. (A)
• As for the general population, people with diabetes are encouraged to consume a variety of fiber-containing foods. However, evidence is lacking to recommend a higher fiber intake for people with diabetes than for the population as a whole. (B)
• Sugar alcohols and nonnutritive sweeteners are safe when consumed within the daily intake levels established by the FDA. (A)

Dietary Fat and Cholesterol in Diabetes Management

• Limit saturated fat to <7% of total calories. (A)
• Intake of trans fat should be minimized. (E)
• In individuals with diabetes, limit dietary cholesterol to <200 mg/day. (E)
• Two or more servings of fish per week (with the exception of commercially fried fish filets) provide n-3 polyunsaturated fatty acids and are recommended. (B)

Protein in Diabetes Management

• For individuals with diabetes and normal renal function, there is insufficient evidence to suggest that usual protein intake (15% to 20% of energy) should be modified. (E)
• In individuals with type 2 diabetes, ingested protein can increase insulin response without increasing plasma glucose concentrations. Therefore, protein should not be used to treat acute or prevent nighttime hypoglycemia. (A)
• High-protein diets are not recommended as a method for weight loss at this time. The long-term effects of protein intake >20% of calories on diabetes management and its complications are unknown. Although such diets may produce short-term weight loss and improved glycemia, it has not been established that these benefits are maintained long term, and long-term effects on kidney function for persons with diabetes are unknown. (E)

Alcohol in Diabetes Management

• If adults with diabetes choose to use alcohol, daily intake should be limited to a moderate amount (one drink per day or less for women and two drinks per day or less for men). (E)
• To reduce risk of nocturnal hypoglycemia in individuals using insulin or insulin secretagogues, alcohol should be consumed with food. (E)
• In individuals with diabetes, moderate alcohol consumption (when ingested alone) has no acute effect on glucose and insulin concentrations but carbohydrate co-ingested with alcohol (as in a mixed drink) may raise blood glucose. (B)

Micronutrients in Diabetes Management

• There is no clear evidence of benefit from vitamin or mineral supplementation in people with diabetes (compared with the general population) who do not have underlying deficiencies. (A)
• Routine supplementation with antioxidants, such as vitamins E and C and carotene, is not advised because of lack of evidence of efficacy and concern related to long-term safety. (A)
• Benefit from chromium supplementation in individuals with diabetes or obesity has not been clearly demonstrated and therefore cannot be recommended. (E)

Nutrition Interventions for Specific Populations

Nutrition Interventions for Type 1 Diabetes

• For individuals with type 1 diabetes, insulin therapy should be integrated into an individual's dietary and physical activity pattern. (E)
• Individuals using rapid-acting insulin by injection or an insulin pump should adjust the meal and snack insulin doses based on the carbohydrate content of the meals and snacks. (A)
• For individuals using fixed daily insulin doses, carbohydrate intake on a day-to-day basis should be kept consistent with respect to time and amount. (C)
• For planned exercise, insulin doses can be adjusted. For unplanned exercise, extra carbohydrate may be needed. (E)

Nutrition Interventions for Type 2 Diabetes

• Individuals with type 2 diabetes are encouraged to implement lifestyle modifications that reduce intakes of energy, saturated and trans fatty acids, cholesterol, and sodium and to increase physical activity in an effort to improve glycemia, dyslipidemia, and blood pressure. (E)
• Plasma glucose monitoring can be used to determine whether adjustments in foods and meals will be sufficient to achieve blood glucose goals or if medication(s) needs to be combined with MNT. (E)

Nutrition Interventions for Older Adults with Diabetes

• Obese older adults with diabetes may benefit from modest energy restriction and an increase in physical activity; energy requirement may be less than for a younger individual of a similar weight. (E)
• A daily multivitamin supplement may be appropriate, especially for those older adults with reduced energy intake. (C)

DM: MNT

MNT and Number/Length of Initial Series of Encounters

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

Strong, Imperative

MNT Long-Term Follow-up Encounters

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

Strong, Imperative

Recommendations Strength Rationale

• Conclusion statement was Grade I.

DM: Assessment and Diabetes

Nutrition Assessment

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

Strong, Imperative

Recommendations Strength Rationale

• Conclusion statement was Grade I

DM: Assessment of Glycemic Control

Assessment of Glycemic Control

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

Strong, Imperative

Recommendation Strength Rationale

• Conclusion statement was Grade I.

DM: Assess Relative Importance of Weight Management

Assess Relative Importance of Weight Management

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

Strong, Conditional

Recommendation Strength Rationale

• Conclusion statement was Grade II.

DM: Intervention Options

Intervention Options

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

Strong, Imperative

Recommendation Strength Rationale

• Conclusion statement was Grade I

DM: Macronutrients

Macronutrient Percentages

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

Strong, Imperative

Recommendation Strength Rationale

• Conclusion statement for Carbohydrate was Grade I
• Conclusion statement for Protein was Grade II

DM: Carbohydrate

Carbohydrate Intake Consistency

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

Strong, Conditional

Carbohydrate Intake and Insulin Dose Adjustment

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

Strong, Conditional

Recommendation Strength Rationale

• Conclusion statement was Grade I

DM: Sucrose and Diabetes

Sucrose Intake

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

Strong, Conditional

Recommendation Strength Rationale

• Conclusion statement was Grade I

DM: Non-nutritive Sweeteners and Diabetes

Non-nutritive Sweeteners

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

Fair, Conditional

Recommendation Strength Rationale

• Conclusion statements were Grade III

DM: Glycemic Index and Diabetes

Glycemic Index

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

Fair, Conditional

Recommendation Strength Rationale

• Conclusion statement was Grade II

DM: Fiber and Diabetes

Fiber Intake and Glycemia

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

Strong, Imperative

Fiber Intake and Cholesterol

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

Strong, Imperative

Recommendation Strength Rationale

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

DM: Protein and Diabetes

Protein Intake and Normal Renal Function

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

Fair, Conditional

Recommendation Strength Rationale

• Conclusion statements were Grade II.

DM: Glucose Monitoring

Blood Glucose Monitoring

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

Fair, Conditional

Frequency of Blood Glucose Monitoring

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

Strong, Conditional

Possible Need for Continuous Glucose Monitoring or More Frequent SMBG

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

Fair, Conditional

Recommendation Strength Rationale

• Conclusion statements were Grades I and II

DM: Coordination of Care and Diabetes

Coordination of Care

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

Consensus, Imperative

Recommendation Strength Rationale

• Conclusion statement was Grade I

DM: Monitor & Evaluate and Diabetes

Monitoring and Evaluation

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

Strong, Imperative

Evaluation of Glycemic Control

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

Consensus, Imperative

Recommendation Strength Rationale

• Conclusion statement for MNT was Grade I

Nutrition and Diabetes

• Dietary modification to achieve target ranges for glucose, lipids, and blood pressure is a tertiary preventive strategy for the complications of diabetes mellitus (grade A).
• Restrict the following in patients with CKD: sodium, 1.5 to 2.4 g/d; phosphate, 800 to 1000 mg/d (stages 3 to 5); potassium, 2 to 3 g/d (stage 5 on hemodialysis) and 3 to 4 g/d (stage 5 on peritoneal dialysis); and protein, 0.8 g/d (stages 1 to 2), 0.6 g/d (stages 3 to 4), 1.2 g/d (stage 5 on hemodialysis), and 1.3 g/d (stage 5 on peritoneal dialysis) (grade A).
• For optimal nitrogen retention, prescribe 1 daily multivitamin and a diet with adequate protein for patients with diabetes mellitus who have nonhealing wounds; consider additional micronutrients such as zinc and oral vitamins C and A depending on the severity of the wounds and the nutritional status of the patient (grade D).

Special Populations

Patients with CKD require special attention to diet, including restrictions of sodium, phosphate (renal failure stages 3-5), potassium, and protein. Patients with diabetes mellitus who have nonhealing wounds should take 1 daily multivitamin and adequate protein for optimal nitrogen retention; additional micronutrients, such as zinc and oral vitamins C and A, can be considered depending on the severity of the wounds and the nutritional status of the patient.

Treating and Controlling Diabetes Complications (Tertiary Prevention)

Microvascular Complications

• Reduction of protein intake to 0.8 to 1.0 g/kg body wt/day in individuals with diabetes and the earlier stages of CKD and to 0.8 g/kg body wt/day in the later stages of CKD may improve measures of renal function (urine albumin excretion rate, glomerular filtration rate) and is recommended. (B)
• MNT that favorably affects cardiovascular risk factors may also have a favorable effect on microvascular complications such as retinopathy and nephropathy. (C)

Treatment and Management of CVD Risk

• Target A1C is as close to normal as possible without significant hypoglycemia. (B)
• For patients with diabetes at risk for cardiovascular disease, diets high in fruits, vegetables, whole grains, and nuts may reduce the risk. (C)
• For patients with diabetes and symptomatic heart failure, dietary sodium intake of <2,000 mg/day may reduce symptoms. (C)
• In normotensive and hypertensive individuals, a reduced sodium intake (e.g., 2,300 mg/day) with a diet high in fruits, vegetables, and low-fat dairy products lowers blood pressure. (A)
• In most individuals, a modest amount of weight loss beneficially affects blood pressure. (C)

DM: Prevention and Treatment of CVD

CVD and Cardioprotective Nutrition Therapy

Cardioprotective nutrition interventions for the prevention and treatment of CVD should be implemented in the initial series of encounters. Diabetes is associated with an increased risk for CVD and glycemic control may improve the lipid profile.

Strong, Imperative

CVD and Cardioprotective Nutrition Interventions

Cardioprotective nutrition interventions for prevention and treatment of CVD include reduction in saturated and trans fats and dietary cholesterol, and interventions to improve blood pressure. Studies in persons with diabetes utilizing these interventions report a reduction in cardiovascular risk and improved cardiovascular outcomes.

Strong, Imperative

Recommendation Strength Rationale

Conclusion statement was Grade I

DM: Protein and Diabetes

Protein Intake and Nephropathy

In persons with diabetic nephropathy, a protein intake of one gram or less per kg body weight per day is recommended. Diets with less than one gram protein per kg body weight per day have been shown to improve albuminuria in persons with nephropathy; however, they have not been shown to have significant effects on GFR.

Fair, Conditional

Protein Intake and Late Stage Nephropathy

For persons with late stage diabetic nephropathy (CKD Stages 3-5), hypoalbuminemia (an indicator of malnutrition) and energy intake must be monitored and changes in protein and energy intake made to correct deficits. A protein intake of approximately 0.7 grams per kg body weight per day has been associated with hypoalbuminemia, whereas a protein intake of approximately 0.9 grams per kg body weight per day has not.

Fair, Conditional

Recommendation Strength Rationale

• Conclusion statement is Grade II

Patients With Type 2 Diabetes Mellitus

Weight control and a controlled-energy diet are essential components of diabetes mellitus management to lower glucose levels and to reduce the risk for cardiovascular disease; cardiovascular risk is lowest when the body mass index is less than 25 kg/m². Physical activity of 30 to 90 minutes per day lowers glucose levels and assists with weight loss or weight maintenance.

Energy Balance, Overweight, and Obesity

• In overweight and obese insulin-resistant individuals, modest weight loss has been shown to improve insulin resistance. Thus, weight loss is recommended for all such individuals who have or are at risk for diabetes. (A)
• For weight loss, either low-carbohydrate or low-fat calorie-restricted diets may be effective in the short term (up to 1 year). (A)
• Physical activity and behavior modification are important components of weight loss programs and are most helpful in maintenance of weight loss. (B)
• Weight loss medications may be considered in the treatment of overweight and obese individuals with type 2 diabetes and can help achieve a 5% to 10% weight loss when combined with lifestyle modification. (B)
• Bariatric surgery may be considered for some individuals with type 2 diabetes and body mass index (BMI) >35 kg/m² and can result in marked improvements in glycemia. The long-term benefits and risks of bariatric surgery in individuals with pre-diabetes or diabetes continue to be studied. (B)

Nutrition Interventions for Type 1 Diabetes

• For individuals with type 1 diabetes, insulin therapy should be integrated into an individual's dietary and physical activity pattern. (E)
• For planned exercise, insulin doses can be adjusted. For unplanned exercise, extra carbohydrate may be needed. (E)

DM: Weight Management

Diabetes and Weight Management

The RD should advise that glycemic control is the primary focus for diabetes management. While decreasing energy intake may improve glycemic control, it is unclear whether weight loss alone will improve glycemic control. Sustained weight loss interventions lasting 1 year or longer reported inconsistent effects on hemoglobin A1C.

Fair, Conditional

Recommendation Strength Rationale

• Conclusion statement was Grade II

DM: Physical Activity

Type 2 Diabetes and Physical Activity

In persons with type 2 diabetes, 90 to 150 minutes of accumulated moderate-intensity aerobic physical activity per week as well as resistance/strength training three times per week is recommended. Both aerobic and resistance training improve glycemic control, independent of weight loss. Physical activity also improves insulin sensitivity and decreases risk for cardiovascular disease and all-cause mortality.

Strong, Conditional

Type 1 Diabetes and Physical Activity

Individuals with type 1 diabetes should be encouraged to engage in regular physical activity. Although exercise is not reported to improve glycemic control in persons with type 1 diabetes, individuals may receive the same benefits from exercise as the general public—decreased risk for cardiovascular disease and improved sense of well-being.

Fair, Conditional

Physical Activity and Insulin/Insulin Secretagogue Use

The RD should instruct individuals on insulin or insulin secretagogues on the safety guidelines to prevent hypoglycemia (frequent blood glucose monitoring and possible adjustment in insulin dose or carbohydrate intake). Research indicates that the incidence of hypoglycemia during exercise may depend on baseline glucose levels.

Fair, Conditional

Recommendation Strength Rationale

• Conclusion statements were Grades I and II

Intensive treatment of diabetes mellitus and conditions known to be risk factors can significantly decrease the development and/or progression of chronic complications.

• Decreased risk of diabetes and cardiovascular disease through promoting healthy food choices and physical activity leading to moderate weight loss
• Normalization of blood glucose levels, lipid and lipoprotein profiles, and blood pressure
• Modification of nutrient intake and lifestyle to prevent, or at least slow, the rate of development of the chronic complications of diabetes

• A primary goal of implementing these recommendations includes improving an adult's ability to achieve optimal nutrition through healthful food choices and a physically active lifestyle. MNT employing either a series of individual or group sessions and employing a variety of nutrition interventions also report improvements in glycemia, lipid profiles and blood pressure, improved weight management, decreased need for medications, and reduction in the risk for onset and progression of comorbidities.
• Although costs of MNT sessions and reimbursement vary, medical nutrition therapy sessions are essential for improved outcomes. MNT education can be considered cost effective when considering the benefits of nutrition interventions on the onset and progression of comorbidities versus the cost of the intervention. Furthermore, MNT can be considered cost effective as interventions for prevention or delay of type 2 diabetes saves the cost of the intervention.

Not stated

Exercise can pose potential risks such as cardiac ischemia, musculoskeletal injuries, and hypoglycemia in patients treated with insulin or insulin secretagogues.

Overall Risk/Harm Considerations

When using these recommendations:

• Review the patient's age, socioeconomic status, cultural issues, and other health conditions.
• Consider a referral to a behavioral specialist if psychosocial issues are a concern.
• Consider a referral to social services to assist patients with financial arrangements if economic issues are a concern.
• Use clinical judgment when evaluating patients with long-standing diabetes and comorbid conditions.

Recommendation Specific Risks/Harms

Macronutrients

Carbohydrate

• Although total carbohydrate content of meals and snacks is the first priority, macronutrient content and total energy intake cannot be ignored as excessive energy intake may lead to weight gain, even if glycemic control is maintained.
• Diets too low in carbohydrates eliminate many foods that are important sources of vitamins, minerals, fiber, and energy.

Sucrose

• Excessive substitution of sucrose for starches could potentially contribute to inadequate intake of foods contributing other essential nutrients. If sucrose-containing foods are habitually added to usual intake, excessive energy intake is a concern.

Protein

• Diets too low in protein and energy intake can lead to hypoalbuminemia (malnutrition) and unintentional weight loss. This needs to be monitored in persons with diabetic neuropathy who are restricting protein intake and may have a diminished appetite.

Self-Monitoring of Blood Glucose

• Frequent glucose self-monitoring may cause pain and discomfort.
• Individuals should know of proper disposal of hazardous waste.

Physical Activity

• Before beginning a program of physical activity more vigorous than brisk walking, people with diabetes should be assessed for conditions that might be associated with an increased risk of cardiovascular disease. Of concern are uncontrolled hypertension, severe autonomic or peripheral neuropathy, and preproliferative or proliferative retinopathy or macular edema.
• In previously sedentary individuals whose 10-year risk of a coronary event is likely to be equal to or greater than 10%, a graded exercise test with electrocardiogram monitoring is recommended.
• In individuals taking insulin or insulin secretagogues, physical activity can cause hypoglycemia if medication dose or carbohydrate intake is not adjusted. Carbohydrate should be ingested if pre-exercise levels are less than 100 mg/dL.

Levels of Substantiation in Evidence-Based Medicine^a

Recommendation Grades in Evidence-Based Medicine^a

American Diabetes Association's Evidence Grading System for Clinical Practice Recommendations

A

Clear evidence from well-conducted, generalizable, randomized controlled trials that are adequately powered, including:

• Evidence from a well-conducted multicenter trial
• Evidence from a meta-analysis that incorporated quality ratings in the analysis
• Compelling non-experimental evidence (i.e., "all or none" rule developed by the Center for Evidence Based Medicine at Oxford*)

Supportive evidence from well-conducted randomized, controlled trials that are adequately powered, including:

• Evidence from a well-conducted trial at one or more institutions
• Evidence from a meta-analysis that incorporated quality ratings in the analysis

*Either all patients died before therapy and at least some survived with therapy, or some patients died without therapy and none died with therapy. Example: use of insulin in the treatment of diabetic ketoacidosis.

B

Supportive evidence from well-conducted cohort studies, including:

• Evidence from a well-conducted prospective cohort study or registry
• Evidence from a well-conducted meta-analysis of cohort studies

Supportive evidence from a well-conducted case-control study

C

Supportive evidence from poorly controlled or uncontrolled studies, including:

• Evidence from randomized clinical trials with one or more major or three or more minor methodological flaws that could invalidate the results
• Evidence from observational studies with high potential for bias (such as case series with comparison with historical controls)
• Evidence from case series or case reports

Conflicting evidence with the weight of evidence supporting the recommendation

E

Expert consensus or clinical experience

Conditional versus Imperative Recommendations

Recommendations can be worded as conditional or imperative statements. Conditional statements clearly define a specific situation, while imperative statements are broadly applicable to the target population without restraints on their pertinence. More specifically, a conditional recommendation can be stated in if/then terminology (e.g., If an individual does not eat food sources of omega-3 fatty acids, then 1g of EPA and DHA omega-3 fatty acid supplements may be recommended for secondary prevention).

In contrast, imperative recommendations "require," or "must," or "should achieve certain goals," but do not contain conditional text that would limit their applicability to specified circumstances. (e.g., Portion control should be included as part of a comprehensive weight management program. Portion control at meals and snacks results in reduced energy intake and weight loss).

Levels of Evidence

Criteria for Recommendation Rating