Nutrition Therapy

Canadian Diabetes Association Clinical Practice Guidelines Expert Committee

Paula D. Dworatzek PhD, RD Kathryn Arcudi PDt, CDE Réjeanne Gougeon PhD Nadira Husein MD, FRCPC John L. Sievenpiper MD, PhD Sandra L. Williams MEd, RD, CDE

  • Key Messages
  • Recommendations
  • Figures
  • Highlights
  • Full Text
  • References

Key Messages

  1. People with diabetes should receive nutrition counselling by a registered dietitian.
  2. Nutrition therapy can reduce glycated hemoglobin (A1C) by 1.0% to 2.0% and, when used with other components of diabetes care, can further improve clinical and metabolic outcomes.
  3. Reduced caloric intake to achieve and maintain a healthier body weight should be a treatment goal for people with diabetes who are overweight or obese.
  4. The macronutrient distribution is flexible within recommended ranges and will depend on individual treatment goals and preferences.
  5. Replacing high glycemic index carbohydrates with low glycemic index carbohydrates in mixed meals has a clinically significant benefit for glycemic control in people with type 1 and type 2 diabetes.
  6. Intensive lifestyle interventions in people with type 2 diabetes can produce improvements in weight management, fitness, glycemic control and cardiovascular risk factors.
  7. A variety of dietary patterns and specific foods have been shown to be of benefit in people with type 2 diabetes.
  8. Consistency in carbohydrate intake and in spacing and regularity in meal consumption may help control blood glucose and weight.

Highlights of Revisions

  • New recommendations suggest nutrition education is effective when delivered in either a small group or one-on-one setting, and that group education should incorporate adult education principles, such as hands-on activities, problem solving, role playing and group discussions.
  • The chapter discusses alternative dietary patterns as an option to improve glycemic control for people with type 2 diabetes.

Recommendations

  1. 1.People with diabetes should receive nutrition counselling by a registered dietitian to lower A1C levels [Grade B, Level 2 (1)], for those with type 2 diabetes; Grade D, Consensus, for type1 diabetes] and to reduce hospitalization rates [Grade C, Level 3 (2)].
  2. 2.Nutrition education is effective when delivered in either a small group or a one-on-one setting [Grade B, Level 2 (3)]. Group education should incorporate adult education principles, such as hands-on activities, problem solving, role playing and group discussions [Grade B, Level 2 (4)].
  3. 3.Individuals with diabetes should be encouraged to follow Eating Well with Canada's Food Guide (5) in order to meet their nutritional needs [Grade D, Consensus].
  4. 4.In overweight or obese people with diabetes, a nutritionally balanced, calorie-reduced diet should be followed to achieve and maintain a lower, healthier body weight [Grade A, Level 1A (6,7)].
  5. 5.In adults with diabetes, the macronutrient distribution as a percentage of total energy can range from 45% to 60% carbohydrate, 15% to 20% protein and 20% to 35% fat to allow for individualization of nutrition therapy based on preferences and treatment goals [Grade D, Consensus].
  6. 6.Adults with diabetes should consume no more than 7% of total daily energy from saturated fats [Grade D, Consensus] and should limit intake of trans fatty acids to a minimum [Grade D, Consensus].
  7. 7.Added sucrose or added fructose can be substituted for other carbohydrates as part of mixed meals up to a maximum of 10% of total daily energy intake, provided adequate control of BG and lipids is maintained [Grade C, Level 3 (8-12)].
  8. 8.People with type 2 diabetes should maintain regularity in timing and spacing of meals to optimize glycemic control [Grade D, Level 4 (13)].
  9. 9.Dietary advice may emphasize choosing carbohydrate food sources with a low glycemic index to help optimize glycemic control [type 1 diabetes: Grade B, Level 2 (14-16) ; type 2 diabetes: Grade B, Level 2 (17)].
  10. 10.Alternative dietary patterns may be used in people with type 2 diabetes to improve glycemic control, (including):
    1. Mediterranean-style dietary pattern [Grade B, Level 2 (18,19)]
    2. Vegan or vegetarian dietary pattern [Grade B, Level 2 (20,21)]
    3. Incorporation of dietary pulses (e.g. beans, peas, chick peas, lentils) [Grade B, Level 2 (22)]
    4. Dietary Approaches to Stop Hypertension (DASH) dietary pattern [Grade C, Level 2 (23)]
  11. 11.An intensive lifestyle intervention program combining dietary modification and increased physical activity may be used to achieve weight loss and improvements in glycemic control and cardiovascular risk factors [Grade A, Level 1A (7)].
  12. 12.People with type 1 diabetes should be taught how to match insulin to carbohydrate quantity and quality [Grade C, Level 2 (24)] or should maintain consistency in carbohydrate quantity and quality [Grade D, Level 4 (25)].
  13. 13.People using insulin or insulin secretagogues should be informed of the risk of delayed hypoglycemia resulting from alcohol consumed with or after the previous evening's meal [Grade C, Level 3 (26,27)] and should be advised on preventive actions such as carbohydrate intake and/or insulin dose adjustments and increased BG monitoring [Grade D, Consensus].

Abbreviation:
BG, blood glucose.

Table 1
Properties of dietary interventions
*↓ = <1% decrease in A1C. adjusted for medication changes.
A1C = glycated hemoglobin; BMI = body mass index; BP = blood pressure; CHO = carbohydrate; CRP = C reactive protein; CV = Cardiovascular; FPG = fasting plasma glucose; GI = gastrointestinal; HDL = high-density lipoprotein; LDL = low-density lipoprotein; MUFA = monounsaturated fatty acid; TC = total cholesterol; TG = triglycerides.

Figure 1
Nutritional management of hyperglycemia in type 2 diabetes.

References

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Reproduced with permission from Canadian Journal of Diabetes © 2013 Canadian Diabetes Association. To cite this article, please refer to For citation.