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Nutrition for Patients with Diabetes Mellitus
Diabetes is one of the most costly and burdensome chronic diseases of our time and is expected to increase in prevalence due at least in part to an aging population, increasing prevalence of overweight and obesity, and growing minority populations that are at higher risk of diabetes. In 2011 to 2012, the estimated unadjusted prevalence of total diabetes using A1c or fasting plasma glucose definitions was 12.3% among American adults, with a higher prevalence among non-Hispanic black, non-Hispanic Asian, and Hispanic individuals (Menke, Casagrande, Geiss, & Cowie, 2015
). An estimated 27.8% of people with diabetes have not been diagnosed (Centers for Disease Control and Prevention, 2014
). Direct and indirect costs of diabetes in the United States are estimated to be $245 billion (Centers for Disease Control and Prevention, 2014
). Diabetes is the seventh leading cause of death in the United States (Centers for Disease Control and Prevention, 2016
This chapter focuses on the prevention of type 2 diabetes and nutrition therapy for type 1 and type 2 diabetes. A third type of diabetes, gestational diabetes, is presented in Chapter 11
Diabetes mellitus is a heterogeneous group of metabolic disorders characterized by hyperglycemia and abnormal insulin metabolism. Absent or ineffective insulin impairs the metabolism of all three macronutrients, resulting in high blood glucose levels, increased levels of fatty acids and triglycerides in the blood, and muscle wasting (Table 19.1
). Diagnostic criteria for diabetes appears in Figure 19.1
Sustained hyperglycemia alters glucose metabolism in virtually every tissue. Damage to small vessels (microvascular) can lead to retinopathy, nephropathy, and neuropathy. Large blood vessel (macrovascular) damage increases the risk of cardiovascular disease and stroke. Other complications include impaired wound healing, gangrene, periodontal disease, and increased susceptibility to other illnesses. Intensive glucose control is associated with significantly lower rates of microvascular (retinopathy and diabetic kidney disease) and neuropathic complications in people with type 2 diabetes and in people newly diagnosed with type 1 diabetes (American Diabetes Association [ADA], 2016e
Table 19.1 Actions of Insulin and Effects of Its Insufficiency
Action of Insulin
Results of Insulin Insufficiency
Promotes uptake of glucose into cells
Promotes formation of glycogen in the liver and muscle
Promotes conversion of excess glucose into triglycerides for storage
Decreases uptake of glucose into muscle and adipose
Decreases glycogen formation in liver and muscle
Increases glycogen breakdown in liver and muscle
Increases gluconeogenesis (the formation of glucose from a noncarbohydrate source, such as amino acids or glycerol)
Promotes uptake of amino acids into tissue protein
Decreases uptake of amino acids into muscle
Decreases protein synthesis
Increases protein breakdown
Promotes formation of adipose from excess fat
Increases production of ketones in the liver
Decreases formation of triglycerides in adipose
Increases triglyceride breakdown in adipose
Increases serum triglyceride and fatty acid levels
Figure 19.1 ▶ Diagnostic criteria for diabetes and prediabetes. (Source: American Diabetes Association. . Classification and diagnosis of diabetes. Diabetes Care, 39 [Suppl. 1], S13-S22.)
Type 1 Diabetes
Type 1 diabetes, formerly known as insulin-dependent diabetes mellitus, is characterized by the absence of insulin. It accounts for 5% to 10% of diabetes cases. Although type 1 can occur at any age, it is most often diagnosed before the age of 18 years. Type 1 diabetes occurs from an autoimmune response that damages or destroys pancreatic beta cells, leaving them unable to produce insulin. Interaction between genetic susceptibility and environmental factors, such as viral infection, is thought to be responsible. The classic symptoms of polyuria, polydipsia, and polyphagia appear abruptly. Sometimes, the first sign of the disease is ketoacidosis. There is no known way to prevent type 1 diabetes. All people with type 1 diabetes require exogenous insulin.
Type 1 Diabetes diabetes characterized by the absence of insulin secretion.
Polyuria excessive urine excretion.
Polydipsia excessive thirst.
Polyphagia excessive appetite.
Ketoacidosis the accumulation of ketone bodies leading to acidosis related to incomplete breakdown of fatty acids from carbohydrate deficiency or inadequate carbohydrate utilization.
Type 2 Diabetes
Insulin Resistance decreased cellular response to insulin.
Impaired Fasting Glucose fasting plasma glucose levels of 100 to 125 mg/dL.
Impaired Glucose Tolerance 2-hour values in the oral glucose tolerance test of 140 to 199 mg/dL.
Hyperinsulinemia elevated blood levels of insulin.
Type 2 diabetes, previously referred to as non-insulin-dependent diabetes, is most often diagnosed after the age of 45 years and accounts for 90% to 95% of diagnosed cases of diabetes. Unlike type 1 diabetes, in which there is a relatively abrupt and absolute end to insulin production, type 2 diabetes is a slowly progressive disease characterized by a combination of insulin resistance
and relative insulin deficiency. When cells do not respond to insulin as they should, the pancreas compensates by secreting higher than normal levels of insulin. Impaired fasting glucose
and impaired glucose tolerance
occur despite high levels of circulating insulin. Over time, chronic hyperinsulinemia
leads to a decrease in the number of insulin receptors on the cells and a further reduction in tissue sensitivity to insulin. Insulin production progressively falls to a deficient level, and frank type 2 diabetes develops. Because hyperglycemia develops gradually in type 2 diabetes and is often not severe enough for patients to recognize any of the classic diabetes symptoms, type 2 diabetes may go
undiagnosed for years. Many patients will have already developed complications by the time of diagnosis (Ahmad & Crandall, 2010
Excess weight is strongly linked to type 2 diabetes. Other risk factors are listed in Box 19.1
. Metabolic syndrome (MetS)
is a cluster of risk factors, such as central obesity, insulin resistance, dyslipidemia, and hypertension that, when combined, increases the risk of type 2 diabetes fivefold and cardiovascular disease threefold (O’Neill & O’Driscoll, 2015
Metabolic Syndrome (MetS) a clustering of interrelated risk factors that includes hypertension, low high-density lipoprotein (HDL) cholesterol, high triglycerides levels, elevated serum glucose, and central or abdominal obesity, as indicated by waist circumference.
is the period of impaired glucose metabolism that precedes the diagnosis of type 2 diabetes (see Fig. 19.1
). In 2011 to 2012, the prevalence of prediabetes was 38% of the overall population (Menke et al., 2015
Prediabetes fasting plasma glucose of 100 to 126 mg/dL or an oral glucose tolerance test of 140 to 199 mg/dL.
Identifying and treating prediabetes is a fundamental strategy for preventing or delaying diabetes (Selph et al., 2015
). Lifestyle interventions can significantly reduce the rate of diabetes onset in people at high risk for developing type 2 diabetes, namely, those with impaired fasting glucose, impaired glucose tolerance, or both (ADA, 2016h). Because of the strong link between excess weight and insulin resistance/type 2 diabetes, modest weight loss achieved through a healthy, hypocaloric eating pattern, increased physical activity, and behavior change is the primary focus of diabetes prevention (Box 19.2
). A major, multicenter clinical trial called the Diabetes Prevention Program (DPP) found that in a diverse group of overweight people with impaired glucose tolerance, nutrition therapy, physical activity, and behavior change decreased the incidence of diabetes by 58% (DPP Research Group, 2002). Average weight loss among study participants was a modest 5% to 7% of initial weight. Participants also benefited from improvements in their lipid profiles, blood pressure, and markers of inflammation (Haffner et al., 2005
; Ratner et al., 2005
). A 10-year follow-up on the original participants showed that the lifestyle intervention group maintained a decreased risk of diabetes over time (DPP Research Group, 2009). Strategies have been observed to promote weight loss are listed in Box 19.3
Current recommendations for prediabetes screening are primarily focused on adults who are overweight or obese based on BMI until patients meet age-related screening at 45 years old (ADA, 2016c). However, a study by Mainous, Tanner, Jo, and Anton, (2016
) found that in healthy weight adults aged 20 years and older, the prevalence of prediabetes was 18.5% in 2012 compared to 10.2% in 1988 to 1994. Although the reason for the increase in prevalence is unclear, researchers speculate that sedentary lifestyle could in part be responsible (Mainous et al., 2016
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 (DSME) the process of facilitating the knowledge, skill, and ability needed to self-manage diabetes.
Diabetes Self-Management Support (DSME/S) the support needed to implement and maintain skills and behaviors needed to self-manage on an ongoing basis.
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
▲ Diabetes self-management education and support for adults with type 2 diabetes: algorithm of care. (Source: Powers, M. A., Bardsley, J., Cypress, M., Duker, P., Funnell, M. M., Fischl, A. H., … Vivian, E. . Diabetes self-management education and support in type 2 diabetes: A joint position statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics.
Journal of the Academy of Nutrition and Dietetics,
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.
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
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
Preserve pleasure in eating
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)
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.
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.
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
, 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.
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