Diabetes is a progressive disease that requires lifelong treatment. The cornerstones of diabetes management are education, nutrition therapy, regular physical activity, and blood glucose monitoring. Patients with type 1 diabetes also require insulin. Patients with type 2 diabetes may also need oral medication, insulin, or a combination of both. A treatment plan is created to help patients achieve metabolic goals (
Box 19.4). Periodic adjustments are needed in response to disease progression or changes in health, age, or life circumstances.
Diabetes Self-Management Education and Support
It is recommended that all people with diabetes participate in
diabetes self-management education (DSME) and
diabetes self-management support (DSME/S) at diagnosis and thereafter as needed to learn and sustain the knowledge, skills, and ability needed
to manage their diabetes (
Fig. 19.2) (ADA, 2016d). Examples of self-care behaviors include healthy eating, being active, monitoring glucose and eating, taking medication, problem solving, and healthy coping. Although DSME/S has been shown to reduce hospital admission and lower estimated lifetime health-care costs due to a lower risk for complications, only a very small percentage of people with newly diagnosed type 2 diabetes actually participate in such a program (
Powers et al., 2015).
Nutrition Therapy for Diabetes
Nutrition therapy is recommended for all people with type 1 or type 2 diabetes (
Evert et al., 2013). Because
atherosclerotic cardiovascular disease (ASCVD) is the most common cause of death among adults with diabetes (
Go et al., 2013), nutrition therapy for diabetes includes strategies to reduce the risk of ASCVD. The goals of nutrition therapy for adults with diabetes are to (
Evert et al., 2013)
Atherosclerotic Cardiovascular Disease (ASCVD) diseases of the cardiovascular system caused by atherosclerosis, which is the accumulation of plague within arteries. Includes acute coronary syndromes, myocardial infarction, stable or unstable angina, coronary or other arterial revascularization, stroke, transient ischemic attack, or peripheral arterial disease.
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Promote healthful eating patterns that emphasize a variety of nutrient-dense foods in the appropriate amounts to improve overall health by attaining or maintaining body weight goals; attaining individualized goals for glucose, lipids, and blood pressure; and delaying or preventing diabetes complications
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Individualize a nutrition plan based on the patients’ preferences and culture, health literacy, access to healthy foods, willingness and ability to change, and barriers to change
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Preserve pleasure in eating
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Provide tools for day-to-day meal planning rather than concentrating on individual macronutrients, micronutrients, or single foods
People with diabetes generally have the same nutritional requirements as the general population and dietary recommendations to promote health and well-being in the general public—lose weight if overweight, limit saturated fat, trans fat, and added sugars, eat more fiber and less sodium—are also appropriate for people with diabetes.
An ideal macronutrient composition for all people with diabetes has not been determined nor is there a universal “diabetic diet” that is recommended for all people with diabetes (
Evert et al., 2013). An individualized approach is used to accomplish the goals listed earlier. The ADA’s nutrition therapy recommendations for diabetes management are presented in the following sections.
Box 19.5 translates nutrition recommendations into healthy eating guidelines.
Calories and Weight Loss
More than 75% of adults with diabetes are at least overweight (
Ali et al., 2013) and almost 50% are obese (
Nguyen, Nguyen, Lane, & Wang, 2011). Strong evidence shows that weight loss improves A1c (
Esposito et al., 2009) and lowers ASCVD risk by increasing HDL cholesterol, decreasing triglycerides, and reducing blood pressure (
Esposito et al., 2009;
Look AHEAD Research Group, 2013). Although some ASCVD risk factors were improved, the landmark Look AHEAD study did
not show a decrease in ASCVD events among participants randomized to intensive lifestyle intervention (
Look AHEAD Research Group, 2013). However, participants reaped other health benefits, such as significant weight loss, which resulted in a lower need for medication to manage glucose and ASCVD risks, less sleep apnea (
Faulconbridge et al., 2012), less depression (
Foster et al., 2009), and improved health-related quality of life (
Williamson et al., 2009). Although a modest sustained weight loss of 5% of initial body weight may improve glucose levels, blood pressure, and/or lipids levels, a sustained weight loss of ≥7% is optimal (ADA, 2016d).
Lifestyle intervention for weight management is a three-pronged approach that includes a healthy hypocaloric eating pattern, an increase in physical activity, and lifestyle behavior changes. A hypocaloric intake may be achieved by lowering calorie intake by 500 to 700 cal/day or by choosing a calorie level within the recommended range of 1200 to 1500 cal/day diet for women and 1500 to 1800 cal/day for men (ADA, 2016d). Strategies associated with weight loss in diabetes prevention studies are listed in
Box 19.3.
To achieve modest weight loss, intensive lifestyle interventions with ongoing support are recommended (ADA, 2016f). Structured programs that focus on diet, physical activity, and behavior change should be composed of ≥16 sessions over a 6-month period. Patients who achieve weight loss should enroll in a long-term (≥1 year) comprehensive weight loss maintenance program. Other options include (ADA, 2016d)
Eating Patterns
A variety of eating patterns have been shown modestly effective in managing diabetes including Mediterranean-style, Dietary Approaches to Stop Hypertension (DASH)-style, vegan or vegetarian, low-fat, and lower carbohydrate diet (
Evert et al., 2013). There is not one “ideal” pattern that all people with diabetes must follow. Total calorie intake is important regardless of the type of eating pattern selected. Patient preferences and health status should determine the type of eating pattern chosen.
Carbohydrate
Although postprandial glucose response is primarily determined by the amount of carbohydrates consumed (and the amount of available insulin), the ideal amount of carbohydrate intake for people with diabetes is unknown (
Evert et al., 2013). Monitoring carbohydrate intake, such as with carbohydrate counting, and how it affects glucose response, is important for improving postprandial glucose control (
Delahanty et al., 2009). Recommendations regarding the timing, amount, and consistency of carbohydrate intake are based on whether the patient manages diabetes with insulin, medication, or only diet and exercise (see “Carbohydrate Counting” section). Consistent with recommendations for the general population, nutrient-dense and high-fiber sources of carbohydrate should be chosen whenever possible over refined or processed carbohydrates with added sodium, fat, and sugar. The majority of carbohydrate calories should come from fruit, vegetables, whole grains, legumes, and low-fat milk.
Sweeteners
Isocalorically of the same calorie level.
Substantial evidence from clinical studies demonstrates that when sucrose is
isocalorically substituted for starch, there is no difference in glycemic control in either type 1 or type 2 diabetes (
Franz et al., 2002). Sucrose and sucrose-containing foods are
not eliminated but should be substituted for other carbohydrates in the meal plan, not eaten as “extras.” Many people with long-standing diabetes resist accepting this shift in thinking because sugar was once taboo. Others find the freedom to choose sweetened foods difficult not to abuse. Even though foods high in sugar do not aggravate glycemic control, they should be minimized to avoid displacing the intake of nutrient-dense foods (
Evert et al., 2013). Sugar-sweetened beverages should be avoided.
Fructose consumed in fruit may result in better glycemic control compared to the same number of calories consumed from sucrose or starch (
Evert et al., 2013). However, the intake of sugar-sweetened beverages containing any sugar, including high-fructose corn syrup and sucrose, should be limited or avoided to lower the risk of weight gain and a detrimental impact on serum lipid levels.
Nonnutritive and Hypocaloric Sweeteners
Nonnutritive sweeteners, such as saccharin, aspartame, acesulfame potassium, and sucralose, are approved for use by the U.S. Food and Drug Administration (FDA) and may safely be used by people with diabetes.
Sugar alcohols (sorbitol, mannitol, and xylitol) are hypocaloric sweeteners that provide fewer calories than sucrose and other natural sweeteners. They appear safe to use but may cause diarrhea when consumed in large amounts, especially in children. Although the potential benefit of using nonnutritive and hypocaloric sweeteners is a decrease in overall calorie and carbohydrate intake if they are used in place of caloric sweeteners and a compensatory increase in calories from other sources does not occur, it is not known if their use leads to weight loss (
Wiebe et al., 2011).
Nonnutritive Sweeteners synthetically made sweeteners that do not provide calories.
Sugar Alcohols natural sweeteners derived from monosaccharides; these are considered low-calorie sweeteners because they are incompletely absorbed. They produce a smaller rise in postprandial glucose levels and insulin secretion than sucrose.