Nutrition in Patients With Diabetes

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Diabetes is a chronic illness that requires a holistic approach in terms of care to prevent both acute and long-term complications. Nutritional management for diabetic patients has been evolving for 100 as the pathophysiological basis of the complications incurred from diabetes becomes more explicit.

Medical nutrition therapy is extremely important for diabetic patients and prediabetic patients so that adequate glycemic control can be achieved. One-on-one consultations with a registered dietician well-versed in diabetic nutrition are most preferable, as has been shown in studies performed in Pakistan [1] and Hungary, [2] which proved the utility of a dietician in improving dietary adherence. Nutrition counseling should be sensitive to the personal needs of the patient and how much effort the patient is willing to put in to making the change to eating appropriately.

Medical nutrition therapy for diabetics can be divided into (1) dietary interventions and (2) physical activity. Lifestyle and dietary modifications form the cornerstone of therapy in type 2 diabetic patients (insulin resistance). In type 1 diabetic patients, who have an insulin deficiency, a balance between insulin and nutrition needs to be obtained for optimal glycemic control. [3]

Nutrition for diabetic patients can be further divided into and continual management of glycemic control. is more for individuals at risk for developing diabetes and for type 2 diabetic patients than for patients who have already developed complications, in order to prevent further progression.

The goals of nutrition in prevention are as follows:

Primary prevention – Identification of the population at high risk (body mass index [BMI] >25), obesity, or prediabetic state and implementation of diet and lifestyle changes

Secondary prevention – Utilization of nutrition as therapeutic modality to achieve euglycemia in diabetic patients

Tertiary prevention – Nutrition as tool to manage the macrovascular and microvascular complications of diabetes and to delay morbidity and mortality

Food groups include macronutrients and micronutrients. There is no optimal diet mix of macronutrients that can be prescribed to the entire diabetic population. Dietary needs must be individualized. Reduction in fat (saturated fats, trans -fats, cholesterol) intake in diabetic patients is aimed at decreasing disease risk by reducing plasma cholesterol and low-density lipoprotein (LDL) cholesterol levels. [4]

Low-carbohydrate and low-fat diets used to achieve initial weight loss are effective for the short term (approximately 1 y) and need monitoring with a lipid profile and renal function tests. Low-carbohydrate diets (20-120 g/d) carry the additional benefit of a favorable lipid profile as compared with low-fat diets. Low-carbohydrate diets have also been noted to decrease fasting plasma glucose values by about 21-28 mg/dL. [5, 6]

The so-called Mediterranean diet may be an option. One study in which subjects (N=322) were randomized to 1 of 3 diets (Mediterranean, restricted-calorie; low-fat, restricted-calorie; low-carbohydrate, non–restricted-calorie) found that at 2-year follow-up, the 36 diabetic subjects assigned to the Mediterranean diet had more favorable fasting plasma glucose and insulin levels compared with those assigned to the low-fat diet. [7]

For patients who are on insulin therapy or oral hypoglycemics, being on a restrictive diet requires adjustment of dosage to prevent hypoglycemia.

Carbohydrate choices in diabetes are as follows:

Carbohydrates necessary for energy, some vitamins, fiber, and dietary palatability and as a major regulator of postprandial glucose levels

Recommended daily allowance for carbohydrates is 130 g/d [8]

Type of carbohydrates (ie, starch, amylose, amylopectin) consumed reflects on postprandial glucose values

Consumption of low–glycemic index foods can result in a drop of 0.4% in hemoglobin A1C compared with high–glycemic index foods [9] ; limitations to this diet choice include bloating and a restrictive diet

Nonnutritive sweeteners have fewer calories compared with regular sucrose used in table sugar but have not been shown to reduce glycemia, accelerate weight loss, or cause weight gain [10]

Dietary fat recommendations in diabetes are as follows:

Total dietary cholesterol consumption of less than 200 mg/d

Saturated fat intake consumption of a maximum of only 7% of one’s daily intake

Servings of nonfried fish recommended weekly as a form of omega-3 fatty acids, which have been postulated to reduce adverse disease outcomes [11]

Plant sterols intake to block intestinal absorption of cholesterol and lower total plasma LDL cholesterol percentage, if intake is around 2 g/d [12]

Protein recommendations in diabetes are that a good quality, high-protein diet is recommended. This measure can aid in achieving weight loss and blood glucose level control. [5]

In addition to the macronutrients, micronutrients are an important component of a balanced diet. Uncontrolled diabetic patients are usually micronutrient deficient because of poor dietary choices. Physicians should encourage meeting daily needs from a healthy, balanced diet rather than from supplementation with multivitamins. [13] If this cannot be achieved, then a daily multivitamin is acceptable. Zinc, copper, and chromium have been studied but do not play any role in achieving tight glycemic control. [14]

Much interest has been sparked in the role of antioxidants and diabetes, as diabetes has been noted to be a state of oxidative stress. Flaxseed has been shown in experiments to decrease inflammatory markers in type 2 diabetic patients, but there are no specific and reliable recommendations. [15] Vitamin E in combination with other antioxidants has the tendency to do more harm than good if taken over prolonged periods. [13] Patients should always be asked about their use of herbal supplements for treatment of their type 2 diabetes, as herbal supplements can interact with other medications and produce unexpected adverse effects. To date, evidence of herbal supplements aiding diabetes management is insufficient. [16]

Adults with diabetes who choose to indulge in alcohol should be cautioned about the risk of nocturnal hypoglycemia if it is consumed without food at night. [17] It has been recommended that men should limit their intake to 2 drinks per day, while for women 1 drink per day is suggested. One alcohol beverage is defined as a 12-oz serving of beer, a 5-oz serving of wine, and a 1.5-oz serving of distilled spirits. Complete abstinence from alcohol should be advised to people who have severe peripheral neuropathy and hypertriglyceridemia.

Physical activity of 150 minutes per week is especially recommended for type 2 diabetic patients, as it causes moderate weight loss and increased insulin sensitivity. If vigorous activity is being performed, then the time duration is 125 minutes per week, with no more than 2 consecutive days without training. [18]

The National Heart, Blood and Lung Institute, [19] using the National Health and Nutrition Examination Survey (NHANES) , defines persons being overweight as having a BMI of 25-29.9 kg/m2 and as being obese as having a BMI greater than 30 kg/m2.

For type 2 diabetic patients with a BMI greater than 35 kg/m2, greater benefit has been noted if they undergo bariatric surgery compared with continual medical therapy with regard to glucose control and weight loss. [20] Weight loss medications help in the initial 5-10% of weight loss and are recommended for patients with established diabetes who have a BMI of greater than 27 kg/m2. [21] Studies have shown that a high BMI with an increased waist circumference (indicator of visceral fat) is a predictor of the development of type 2 diabetes and cardiovascular disease. In both short- and long-term studies evaluating weight loss and its resultant effect on a drop in hemoglobin A1C, however, results have not been consistent.

Yoga has been suggested as an alternative for severe diabetic patients who may be unable to participate in strenuous activity. Malhotra et al undertook a 20-patient study in Delhi, India and concluded that yoga has a beneficial effect on glucose control, as well as promoting weight loss. [22]

A current trial, Look AHEAD (Action for HEAlth in Diabetes), [23] has been designed to evaluate outcomes of long-term weight loss on glycemia and the development of cardiovascular disease. For type 1 diabetic patients with macrovascular or microvascular complications, an individualized exercise regimen is warranted as strenuous exercise can result in complications. If patients have active proliferative diabetic retinopathy, they should be advised to refrain from strenuous exercise or Valsalva maneuvers, as these can precipitate vitreous hemorrhage. Patients with microalbuminuria (>20 mg/min albumin excretion) or frank proteinuria (>200 mg/min protein excretion) should not engage in high-intensity physical activity.

In type 1 diabetic patients, the risk for developing hypoglycemia exists during, immediately after, or several hours after of engaging in physical activity, which mandates adjustment in the therapeutic regimen patients may be following. Supplemental carbohydrates should be taken if finger-stick glucose values are less than 100 mg/dL prior to initiating exercise.

Key precautions for exercise programs in diabetes are as follows:

Evaluation of the patient prior to embarking on an exercise regimen, with a thorough physical examination and careful medical tests, with documentation of grade of retinopathy, nephropathy, and neuropathy (both peripheral and autonomic)

Baseline resting ECG to check for any ST and T segment abnormalities; additional radionuclide stress testing may be warranted

Doppler ultrasound and ankle brachial index if evidence of peripheral arterial disease is present

Should a patient with sensitive feet undertake exercise, ulceration and fractures may result; weight-bearing exercises should be limited; swimming is the ideal exercise in this case

A warm-up and cool-down session of 5-10 minutes must always be undertaken

Use of silica gel or air midsoles, in addition to polyester or blend (cotton-polyester) socks, to prevent blisters and maintain circulation

Footwear should be appropriate at all times

Patient examination of the feet prior to, as well as after, undertaking physical exercise

Diabetic bracelet should be worn and steps should be taken to ensure its visibility

An average of 17 oz of fluids should be consumed at least 2 hours prior to the start of exercise in order to maintain adequate hydration

Managing diabetes requires a multidisciplinary approach, and nutrition and physical exercise are 2 significant facets to help reduce the global burden of the diabetes epidemic. To ensure successful outcomes, physicians, patients, and dietitians need to work together. Studies have shown one-on-one consultations with a qualified registered dietician improve patient adherence to prescribed diabetic diets. [1, 2]

The cornerstones of therapy for type 2 diabetic patients are diet and lifestyle modifications. For type 1 diabetic patients, the goal of optimal glycemic control can be achieved with a balance between insulin and nutrition needs.

Hakeem R, Fawwad A, Siddiqui A, Ahmadani MY, Basit A. Efficacy of dietetics in low resource communities: dietary intake and BMI of type 2 diabetics living in Karachi before and after receiving dietician’s guidance. Pak J Biol Sci. 2008 May 15. 11(10):1324-9. [Medline].

Rurik I, Ruzsinko K, Jancso Z, Antal M. Nutritional counseling for diabetic patients: a pilot study in hungarian primary care. Ann Nutr Metab. 2010. 57(1):18-22. [Medline].

Stephenson EJ, Smiles W, Hawley JA. The relationship between exercise, nutrition and type 2 diabetes. Med Sport Sci. 2014. 60:1-10. [Medline].

Fuller NR, Sainsbury A, Caterson ID, Markovic TP. Egg consumption and human cardio-metabolic health in people with and without diabetes. Nutrients. 2015 Sep 3. 7(9):7399-420. [Medline].

Gannon MC, Nuttall FQ. Effect of a high-protein, low-carbohydrate diet on blood glucose control in people with type 2 diabetes. Diabetes. 2004 Sep. 53(9):2375-82. [Medline].

Liu Y, Cotillard A, Vatier C, et al. A dietary supplement containing cinnamon, chromium and carnosine decreases fasting plasma glucose and increases lean mass in overweight or obese pre-diabetic subjects: a randomized, placebo-controlled trial. PLoS One. 2015. 10(9):e0138646. [Medline].

Shai I, Schwarzfuchs D, Henkin Y, et al. Weight loss with a low-carbohydrate, Mediterranean, or low-fat diet. N Engl J Med. 2008 Jul 17. 359(3):229-41. [Medline].

Bantle JP, Wylie-Rosett J, Albright AL, Apovian CM, Clark NG. Nutrition recommendations and interventions for diabetes: a position statement of the American Diabetes Association. Diabetes Care. 2008 Jan. 31 Suppl 1:S61-78. [Medline].

Franz MJ, Bantle JP, Beebe , et al. Evidence-based nutrition principles and recommendations for the treatment and prevention of diabetes and related complications. Diabetes Care. 2003 Jan. 26 Suppl 1:S51-61. [Medline].

Raben A, Vasilaras TH, Moller AC, Astrup A. Sucrose compared with artificial sweeteners: different effects on ad libitum food intake and body weight after 10 wk of supplementation in overweight subjects. Am J Clin Nutr. 2002 Oct. 76(4):721-9. [Medline].

Wang C, Harris WS, Chung M, et al. n-3 Fatty acids from fish or fish-oil supplements, but not alpha-linolenic acid, benefit cardiovascular disease outcomes in primary- and secondary-prevention studies: a systematic review. Am J Clin Nutr. 2006 Jul. 84(1):5-17. [Medline].

Lee YM, Haastert B, Scherbaum W, Hauner H. A phytosterol-enriched spread improves the lipid profile of subjects with type 2 diabetes mellitus–a randomized controlled trial under free-living conditions. Eur J Nutr. 2003 Apr. 42(2):111-7. [Medline].

Hasanain B, Mooradian AD. Antioxidant vitamins and their influence in diabetes mellitus. Curr Diab Rep. 2002 Oct. 2(5):448-56. [Medline].

Cunningham JJ. Micronutrients as nutriceutical interventions in diabetes mellitus. J Am Coll Nutr. 1998 Feb. 17(1):7-10. [Medline].

Pan A, Demark-Wahnefried W, Ye X, et al. Effects of a flaxseed-derived lignan supplement on C-reactive protein, IL-6 and retinol-binding protein 4 in type 2 diabetic patients. Br J Nutr. 2009 Apr. 101(8):1145-9. [Medline].

Yeh GY, Eisenberg DM, Kaptchuk TJ, Phillips RS. Systematic review of herbs and dietary supplements for glycemic control in diabetes. Diabetes Care. 2003 Apr. 26(4):1277-94. [Medline].

Turner BC, Jenkins E, Kerr D, Sherwin RS, Cavan DA. The effect of evening alcohol consumption on next-morning glucose control in type 1 diabetes. Diabetes Care. 2001 Nov. 24(11):1888-93. [Medline].

Hordern MD, Dunstan DW, Prins JB, Baker MK, Singh MA, Coombes JS. Exercise prescription for patients with type 2 diabetes and pre-diabetes: a position statement from Exercise and Sport Science Australia. J Sci Med Sport. 2012 Jan. 15(1):25-31. [Medline].

Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: executive summary. Expert Panel on the Identification, Evaluation, and Treatment of Overweight in Adults. Am J Clin Nutr. 1998 Oct. 68(4):899-917. [Medline].

Mingrone G, Panunzi S, De Gaetano A, et al. Bariatric surgery versus conventional medical therapy for type 2 diabetes. N Engl J Med. 2012 Apr 26. 366(17):1577-85. [Medline].

Norris SL, Zhang X, Avenell A, et al. Efficacy of pharmacotherapy for weight loss in adults with type 2 diabetes mellitus: a meta-analysis. Arch Intern Med. 2004 Jul 12. 164(13):1395-404. [Medline].

Malhotra V, Singh S, Tandon OP, Sharma SB. The beneficial effect of yoga in diabetes. Nepal Med Coll J. 2005 Dec. 7(2):145-7. [Medline].

Ryan DH, Espeland MA, Foster GD, et al. Look AHEAD (Action for Health in Diabetes): design and methods for a clinical trial of weight loss for the prevention of cardiovascular disease in type 2 diabetes. Control Clin Trials. 2003 Oct. 24(5):610-28. [Medline].

Fazia Mir, MD Fellow, Department of Gastroenterology, University of Missouri-Columbia School of Medicine

Fazia Mir, MD is a member of the following medical societies: American College of Physicians

Disclosure: Nothing to disclose.

Faraaz Zafar Drake University

Disclosure: Nothing to disclose.

George T Griffing, MD Professor Emeritus of Medicine, St Louis University School of Medicine

George T Griffing, MD is a member of the following medical societies: American Association for the Advancement of Science, International Society for Clinical Densitometry, Southern Society for Clinical Investigation, American College of Medical Practice Executives, American Association for Physician Leadership, American College of Physicians, American Diabetes Association, American Federation for Medical Research, American Heart Association, Central Society for Clinical and Translational Research, Endocrine Society

Disclosure: Nothing to disclose.

George T Griffing, MD Professor Emeritus of Medicine, St Louis University School of Medicine

George T Griffing, MD is a member of the following medical societies: American Association for the Advancement of Science, International Society for Clinical Densitometry, Southern Society for Clinical Investigation, American College of Medical Practice Executives, American Association for Physician Leadership, American College of Physicians, American Diabetes Association, American Federation for Medical Research, American Heart Association, Central Society for Clinical and Translational Research, Endocrine Society

Disclosure: Nothing to disclose.

Nutrition in Patients With Diabetes

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