A direct comparison of recommendations presented in the above guidelines for the nutritional management of diabetes mellitus is provided below.
Areas of Agreement
Medical Nutrition Therapy (MNT)
The guidelines agree that MNT is an essential component of any comprehensive diabetes mellitus management program, that it should be individualized for each patient, and that it is best provided by a registered dietitian familiar with the components of diabetes MNT. AND states 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. ADA notes that nutrition counseling should be sensitive to the individual's personal needs, willingness to change, and ability to make changes.
Carbohydrate
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. The guideline developers further agree that carbohydrate intake should be kept consistent on a day-to-day basis with respect to time and amount, and that for individuals who are on insulin pump therapy, insulin doses should be adjusted based on the carbohydrate content of meals and snacks.
Protein
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. ADA adds that protein should not be used to prevent or treat acute nighttime hypoglycemia in individuals with T2DM, and that high-protein diets are not recommended as a method for weight loss at this time.
Fiber
ADA 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. AND notes that recommendations for fiber intake for people with diabetes are similar to the recommendations for the general public (14 g/1000 kcal), and that 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 demonstrated beneficial effects on glycemia. AND 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%.
Sucrose
The groups agree that sucrose does not need to be avoided by patients with diabetes mellitus, but when consumed, should replace other carbohydrates. ADA 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. AND 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.
Alcohol Consumption
According to ADA, 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. ADA also notes that to reduce risk of nocturnal hypoglycemia in individuals using insulin or insulin secretagogues, alcohol should be consumed with food. The developer adds 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. AND does not address alcohol consumption.
Dietary Fat and Cholesterol
The guidelines agree that intake of trans fats should be minimized. ADA notes that n-3 polyunsaturated fatty acids have beneficial effects on the lipid profile, and 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. AND 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.
Micronutrients
According to ADA — the only group to address the use of micronutrients — 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.
Nutritional Interventions for Preventing and Managing Diabetes Complications
Both groups agree that protein intake should be restricted in individuals with diabetes and CKD. Recommendations are similar, with ADA recommending 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. AND 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 g/kg body weight/day has been associated with hypoalbuminemia, whereas a protein intake of approximately 0.9 g/kg body weight/day has not.
Both guideline developers provide specific nutrition interventions for the prevention and treatment of CVD. AND 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. ADA states that for patients with diabetes at risk for cardiovascular disease, diets high in fruits, vegetables, whole grains, and nuts may reduce the risk.
Physical Activity and Weight Management
AND recommends 90 to 150 mins/week of physical activity for individuals with T2DM to improve glycemic control, as well as resistance/strength training three times per week. According to the developer, 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. ADA recommends weight loss for overweight and obese insulin-resistant individuals, adding that weight loss medications and bariatric surgery may be considered for certain patients with type 2 diabetes. According to AND, while decreasing energy intake may improve glycemic control, it is unclear whether weight loss alone will improve glycemic control.
Areas of Difference
There are no significant areas of difference between the guidelines.
