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A direct comparison of the American Association of Clinical Endocrinologists (AACE), American Diabetes Association (Am Diabetes Assoc) and the American Dietetic Association (Am Dietetic Assoc) recommendations for the nutritional management of diabetes mellitus is provided in the following tables. Excluded from this synthesis are recommendations for the nutritional management of gestational diabetes mellitus.
The tables below provide a side-by-side comparison of key attributes of each guideline, including specific interventions and practices that are addressed. The language used in these tables, particularly that which is used in Table 3, Table 4, and Table 5 is in most cases taken verbatim from the original guidelines:
Following the content comparison tables, the areas of agreement and differences among the guidelines are identified.
Abbreviations
TABLE 4: BENEFITS AND HARMS | |
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Benefits | |
AACE (2007) |
Intensive treatment of diabetes mellitus and conditions known to be risk factors can significantly decrease the development and/or progression of chronic complications. |
Am Diabetes Assoc (2008) |
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Am Dietetic Assoc (2008) |
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Harms | |
AACE (2007) |
Not stated |
Am Diabetes Assoc (2008) |
Exercise can pose potential risks such as cardiac ischemia, musculoskeletal injuries, and hypoglycemia in patients treated with insulin or insulin secretagogues. |
Am Dietetic Assoc (2008) |
Overall Risk/Harm Considerations When using these recommendations:
Recommendation Specific Risks/Harms Macronutrients Carbohydrate
Sucrose
Protein
Self-Monitoring of Blood Glucose
Physical Activity
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TABLE 5: EVIDENCE RATING SCHEMES AND REFERENCES | ||||||||||||||||||||||||||||||||||||||||||
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AACE (2007) |
Levels of Substantiation in Evidence-Based Medicinea
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Recommendation Grades in Evidence-Based Medicinea
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Am Diabetes Assoc (2008) |
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:
Supportive evidence from well-conducted randomized, controlled trials that are adequately powered, including:
*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:
Supportive evidence from a well-conducted case-control study C Supportive evidence from poorly controlled or uncontrolled studies, including:
Conflicting evidence with the weight of evidence supporting the recommendation E Expert consensus or clinical experience |
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Am Dietetic Assoc (2008) |
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). |
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Levels of Evidence
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Criteria for Recommendation Rating
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The American Association of Clinical Endocrinologists (AACE), the American Diabetes Association (Am Diabetes Assoc) and the American Dietetic Association (Am Dietetic Assoc) present recommendations for nutritional management of diabetes mellitus.
The guidelines agree that MNT is an essential component of any comprehensive diabetes mellitus management program and that it should be individualized for each patient. Am Diabetes Assoc and American Dietetic Assoc agree that MNT is best provided by a registered dietitian familiar with the components of diabetes MNT. AACE and American Dietetic Assoc state that factors to take into consideration while developing a diet include food intake/preferences, lifestyle (such as physical activity), medication regimen, metabolic control, glycemic control and anthropometric measurements. Am Diabetes Assoc notes that nutrition counseling should be sensitive to the individual's personal needs, willingness to change, and ability to make changes.
The groups agree that a dietary pattern that includes carbohydrate from fruits, vegetables, whole grains, legumes, and low-fat milk should be encouraged. There is also overall agreement that for individuals with T1DM, insulin therapy should be integrated into the dietary and physical activity pattern, and that the key to successful MNT is synchronizing carbohydrate intake with insulin therapy. Am Diabetes Assoc and Am Dietetic Assoc agree that carbohydrate intake should be kept consistent on a day-to-day basis with respect to time and amount. These two groups also agree that for individuals who are on insulin pump therapy, insulin doses should be adjusted based on the carbohydrate content of meals and snacks. AACE notes that the use of basal-bolus insulin therapy using insulin analogs or continuous subcutaneous insulin infusion (insulin pump therapy) in conjunction with carbohydrate counting is the most physiologic treatment and provides the greatest flexibility in terms of food choices and timing of meals. They add that basal-bolus therapy using a consistent carbohydrate meal plan can be equally effective for patients unable or unwilling to count carbohydrates.
The guideline groups agree that protein intake in individuals with diabetes mellitus and normal renal function should be the same as for patients who do not have diabetes mellitus, 15% to 20% of daily energy intake. Am Diabetes Assoc adds that protein should not be used to treat acute or prevent nighttime hypoglycemia in individuals with T2DM, and that high-protein diets are not recommended as a method for weight loss at this time.
Am Diabetes Assoc notes that, as for the general population, people with diabetes are encouraged to consume a variety of fiber-containing foods. They add, however, that evidence is lacking to recommend a higher fiber intake for people with diabetes than for the population as a whole. AACE specifies that individuals with diabetes should consume fiber in amounts of 25 to 50 g/day, or 15 to 25 g/1000 kcal ingested. Am Dietetic Assoc notes that recommendations for fiber intake for people with diabetes are similar to the recommendations for the general public (14 g/1000 kcal). While diets containing 44 to 50 grams of fiber daily are reported to improve glycemia, Am Dietetic Assoc continues, more usual fiber intakes (up to 24 grams daily) have not shown beneficial effects on glycemia. Am Dietetic Assoc also notes that including foods containing 25 to 30 grams of fiber per day, with special emphasis on soluble fiber sources (7 to 13 grams), can help to lower cholesterol. They add that 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%.
The groups agree that sucrose does not need to be avoided by patients with diabetes mellitus. AACE and Am Dietetic Assoc agree that that when consumed, however, sucrose should replace other carbohydrates. Am Diabetes Assoc notes that, in addition to being substituted for other carbohydrates, sucrose may also be added to the meal plan, but if so, should be covered with insulin or other glucose-lowering medications. Am Dietetic Assoc notes that 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.
AACE and Am Diabetes Assoc agree that for adults with diabetes who choose to consume alcohol, consumption should be limited to 1 drink per day for women and 2 drinks per day for men. Am Diabetes Assoc also notes that to reduce risk of nocturnal hypoglycemia in individuals using insulin or insulin secretagogues, alcohol should be consumed with food. They add that 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. Am Dietetic Assoc does not address alcohol consumption.
The guidelines agree that intake of trans fats should be minimized. AACE states that total dietary fat should generally comprise less than 30% of daily energy intake; the other two groups do not specify a percentage of recommended dietary fat intake. AACE and Am Diabetes Assoc are in agreement that n-3 polyunsaturated fatty acids have beneficial effects on the lipid profile, with AACE specifying that these should comprise most fat intake. Am Diabetes Assoc notes that 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. Am Dietetic Assoc cites reduction in saturated and trans fats, as well as reduction of dietary cholesterol and interventions to improve blood pressure, as effective cardioprotective nutrition interventions for prevention and treatment of CVD.
Of the two guideline groups that address the use of micronutrients, AACE and Am Diabetes Assoc, neither group recommends they be used routinely. According to Am Diabetes Assoc, 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. AACE recommends their use only for patients with diabetes mellitus who have nonhealing wounds, recommending 1 daily multivitamin and adequate protein for optimal nitrogen retention. They add that 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.
All three groups agree that protein intake should be restricted in individuals with diabetes and CKD. Recommendations are similar with AACE recommending 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). Am Diabetes Assoc recommends 0.8 to 1.0 g/kg body weight/day in the earlier stages of CKD and to 0.8 g/kg body weight/day in the later stages of CKD. Am Dietetic Assoc recommends a protein intake of 1 g or less/kg body weight/day during the first two stages. They add that for persons with late stage diabetic nephropathy (CKD Stages 3-5), 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.
AACE also provides recommendations for the restriction of sodium, phosphate, potassium for individuals with diabetes and CKD.
Am Diabetes Assoc and Am Dietetic Assoc provide specific nutrition interventions for the prevention and treatment of CVD. Am Dietetic Assoc recommends that cardioprotective interventions be implemented in the initial series of encounters, and should include reduction in saturated and trans fats and dietary cholesterol, as well as interventions to improve blood pressure. Am Diabetes Assoc states that for patients with diabetes at risk for cardiovascular disease, diets high in fruits, vegetables, whole grains, and nuts may reduce the risk.
AACE and Am Dietetic Assoc recommend physical activity (30 to 90 mins/day [AACE]; 90 to 150 mins/week [Am Dietetic Assoc]) for individuals with T2DM to improve glycemic control. Am Dietetic Assoc also recommends resistance/strength training three times per week. According to Am Dietetic Assoc, although exercise is not reported to improve glycemic control in persons with T1DM, these individuals should be encouraged to engage in regular physical activity to receive the same benefits from exercise as the general public (e.g., decreased risk for cardiovascular disease and improved sense of well-being).
The guidelines also address the role of weight loss in glycemic management. Am Diabetes Assoc recommends weight loss for overweight and obese insulin-resistant individuals. They add that that weight loss medications and bariatric surgery may be considered for certain patients with type 2 diabetes. According to the Am Dietetic Assoc, while decreasing energy intake may improve glycemic control, it is unclear whether weight loss alone will improve glycemic control.
Recommendations regarding intake of saturated fat and cholesterol differ slightly. Am Diabetes Assoc recommends that saturated fat be limited to <7% of total daily calories, and cholesterol limited to <200g per day. AACE, however, recommends these same intakes only in patients with an LDL-C level greater than 100 mg/dL. Otherwise, they recommend saturated fat be limited to <10% of daily energy intake and cholesterol limited to <300 mg/day.
This synthesis was prepared by NGC on January 8, 2009. The information was verified by the American Dietetic Association on February 5, 2009 and by AACE on March 2, 2009.
Internet citation: National Guideline Clearinghouse (NGC). Guideline synthesis: Nutritional management of diabetes mellitus. In: National Guideline Clearinghouse (NGC) [website]. Rockville (MD): 2009 Mar. [cited YYYY Mon DD]. Available: http://www.guideline.gov.