TYPE 2
DIABETES
A Guide to Nutrition
ccording to the National Institute of Diabetes and Digestive and Kidney Diseases NIDDK of the National Institutes of Health, an estimated 167 million Americans have been diagnosed with diabetes The prevalence of diabetes increased 61 between 1990 and 20011 In addition, it is estimated that about one-third of all cases of diabetes have not been diagnosed2 At high risk for type 2 diabetes are the 16 million adults with pre-diabetes3 and 47 million adults who have the metabolic syndrome4 Based on current trends, the Centers for Disease Control and Prevention projects that by 2050 the prevalence will have increased by 1655
A
The financial toll for diabetes, considering both medical expenditures and lost productivity, was 132 billion in 20026 Considering both the economic and human consequences, many health organizations and health care professionals are seeking innovative methods to prevent and treat this serious and as yet incurable illness The purpose of this professional reference paper and accompanying consumer handouts is to address the fundamentals of nutrition care related to diabetes For a more comprehensive guide to nutrition therapy for
clinicians working in diabetes care, refer to the online resources and cited references BACKGROUND: TYPE 2 DIABETES AND PRE-DIABETES Type 2 diabetes accounts for 90 to 95 of all diagnosed cases of diabetes The disease is associated with older age, obesity, family history of diabetes, physical inactivity, impaired glucose tolerance, history of gestational diabetes and certain race/ethnic backgrounds AfricanAmericans, Latinos, Native Americans, AsianAmericans, Pacific Islanders7 Type 2 diabetes is becoming increasingly more common in children, adolescents and young adults, concomitant with the rise in obesity among these groups8 Diabetes is a progressive disease that is often not diagnosed until after the initial symptoms occur Type 2 diabetes results from a combination of cellular insulin resistance and insulin deficiency caused by beta cell failure Initially, to overcome insulin resistance, there is a compensatory increase in insulin secretion, which maintains normal glucose concentrations But as the disease progresses, insulin production gradually decreases Hyperglycemia is first exhibited by elevations in postprandial glucose due to insulin resistance at the cellular level
However, as insulin secretion decreases, hepatic glucose production increases causing an increase in fasting glucose levels Compounding the problem is the deleterious effect of hyperglycemia itself glucotoxicity upon both insulin sensitivity and insulin secretion9 Insulin resistance also affects adipocytes, leading to lipolysis and an increase in circulating
free fatty acids This higher level of free fatty acids contributes to the decrease in insulin sensitivity at the cellular level, impairs insulin secretion and augments hepatic glucose production lipotoxicity All of these defects cellular, hepatic and beta cell combine to play a role in the development and progression of type 2 diabetes While individuals with type 1 diabetes always require exogenous insulin, the preferred initial treatment for patients with type 2 diabetes is nutrition therapy and regular physical activity As the disease progresses, however, oral glucose-lowering agents and insulin often need to be added The need for insulin is not due to a failure of nutrition therapy or oral medications, but rather is the result of the pancreas failing to produce the insulin needed to maintain adequate glucose control
Throughout the disease progression, nutrition therapy and physical activity continue to be essential and will be combined with oral medications or insulin10 Pre-diabetes is a condition that occurs when fasting glucose or glucose tolerance test levels are higher than normal but below the criteria for diabetes diagnosis See chart on page 5 Several research studies have shown that among individuals with pre-diabetes, there is a significantly increased risk of cardiovascular disease CVD and premature death compared to individuals with normal blood glucose levels11-15 Although risk factors for CVD such as high blood lipid levels are more prevalent among this group, they are not sufficient to fully explain the increased incidence of CVD and death among individuals with pre-diabetes16 Diabetes requires permanent changes in an individuals nutrition and lifestyle habits To manage diabetes, several tools are typically implemented, including metabolic outcome monitoring, nutrition therapy, physical activity, medication and self-management education The goal of treatment is to provide the client with the tools to achieve the best possible control of blood glucose, lipids and blood pressure in
order to prevent, delay or stop the vascular complications associated with diabetes
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RISK FACTORS, DIAGNOSIS AND POTENTIAL MEDICAL COMPLICATIONS OF TYPE 2 DIABETES There are a number of known risk factors for type 2 diabetes: Genetics Along with environmental factors, genetics clearly plays a role in the development of type 2 diabetes17 Being overweight Obese individuals have a fivefold higher risk of acquiring type 2 diabetes compared to normal-weight individuals Nevertheless, type 2 diabetes is frequently diagnosed in nonobese individuals and many obese individuals never develop type 2 diabetes18 Central/abdominal obesity is a strong risk factor for type 2 diabetes, independent of total obesity level Being sedentary A sedentary lifestyle is a major risk factor for type 2 diabetes A number of epidemiological studies show that both moderate and vigorous exercise performed regularly can significantly improve insulin sensitivity and reduce the risk of developing type 2 diabetes19, 20 Age As individuals age, the incidence of type 2 diabetes increases This effect is likely due to several factors, including weight gain, decreased level of physical activity and age-related decreases
in insulin production and insulin sensitivity7 High-fat diet Independent of overall caloric intake, a diet high in fat appears to increase the risk of type 2 diabetes, although this effect has not been shown in all studies21, 22 With the exception of omega-3 polyunsaturated fatty acids, all types of dietary fat, particularly saturated fat, may have an adverse effect on insulin sensitivity21, 22 Insulin resistance Insulin resistance occurs when there is a low or impaired cellular response to insulin Testing for Diabetes The American Diabetes Association recommends diabetes testing for all adults starting at age 45 If results are normal, testing should be repeated at 3-year intervals23 Testing should be considered at a younger age or performed more frequently if any of the following apply to an individual:
Overweight defined as a body mass index [BMI] greater than the 85th percentile for age and sex BMI 25 kg/m2 Habitually physically inactive First-degree relative with diabetes High-risk ethnic background African-American, Latino, Native American, Asian-American, Pacific Islander Previous diagnosis with gestational diabetes or delivery of a baby weighing greater than 9 lbs
Hypertension 140/90 mm Hg HDL cholesterol level 35 mg/dl and/or a triglyceride level 250 mg/dl Impaired glucose tolerance or impaired fasting glucose at previous testing Other clinical conditions associated with insulin resistance History of vascular disease Children who are overweight and who also have at least two risk factors for diabetes should be screened Risk factors include a family history of type 2 diabetes, high-risk ethnic/racial background or clinical conditions associated with insulin resistance Screening for these children should begin at 10 years of age or at the onset of puberty, and thereafter every 2 years Diagnostic Criteria The most common tests used to diagnose diabetes and pre-diabetes are fasting plasma glucose FPG and the oral glucose tolerance test OGTT The FPG is the preferred method for diagnosing diabetes because it is easiest to use, most acceptable to patients and the least costly The OGTT is not recommended for routine clinical use The A1c test is not recommended as a tool for diagnosing diabetes; however, it is a valuable indicator of longer term glycemic control An A1c test measures average glycemic control over the preceding 2 to 3 months and
is used to assess treatment efficacy The American Diabetes Association recommends that A1c be measured approximately every 3 months
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BLOOD GLUCOSE: NORMAL, PRE-DIABETES AND DIABETES FPG Normal Pre-diabetes Diabetes 110 mg/dl 110 and 126 mg/dl 126 mg/dl OGTT 140 mg/dl 140 and 200 mg/dl 200 mg/dl
From: American Diabetes Association Standards of medical care for patients with diabetes Position Statement Diabetes Care 26Suppl 1:S33-S50, 2003
CRITERIA FOR THE DIAGNOSIS OF DIABETES
Diabetes is the leading cause of blindness among adults Forty-three percent of new cases of end-stage renal disease are attributed to diabetes Sixty to seventy percent of individuals with diabetes have some form of nervous system damage As a result of this damage, more than 60 of non-traumatic lower limb amputations occur among individuals with diabetes Individuals with diabetes are more susceptible to other illnesses such as pneumonia and influenza and, once they get sick, often have a worse prognosis compared to individuals without diabetes NUTRITION RECOMMENDATIONS FOR THE TREATMENT AND PREVENTION OF DIABETES AND RELATED COMPLICATIONS The nutrition principles and recommendations issued by the
American Diabetes Association are classified into four categories according to their level of supporting evidence22 The guidelines provide 51 nutrition recommendations divided into 15 categories Most recommendations pertain to individuals with type 1 or type 2 diabetes and review the major nutrients in the diet such as carbohydrate, protein, fat, energy balance and alcohol A separate category addresses diabetes prevention Other recommendation categories focus on special populations and clinical conditions For each recommendation, a grade is assigned based on the American Diabetes Associations evidence grading system for clinical practice recommendations The highest ranking, A, is assigned when there is supportive evidence from multiple, well-controlled studies; B is an intermediate rating; and an E rating represents recommendations based on expert consensus
1 Symptoms of diabetes and a casual plasma glucose 200 mg/dl Casual is defined as any time of day without regard to time of last meal The classic symptoms of diabetes include polyuria, polydipsia and unexplained weight loss or
2 Fasting plasma glucose FPG 126 mg/dl Fasting is defined as no caloric intake for at least 8
hours
or
3 2-hour plasma glucose PG 200 mg/dl during an
oral glucose tolerance test OGTT The test should be performed as described by the WHO, using a glucose load containing the equivalent of 75 grams anhydrous glucose dissolved in water
In the absence of unequivocal hyperglycemia with acute metabolic decompensation, these criteria should be confirmed by repeat testing on a different day Expert Committee on the Diagnosis and Classification of Diabetes Mellitus Diabetes Care 26Suppl 1:S12, 2003
Medical Complications The potential health effects of diabetes are serious and devastating7: Adults with diabetes are two to four times more likely to die from heart disease than adults without diabetes Heart disease is the leading cause of diabetes-related death Individuals with diabetes are at greater risk for stroke Almost three-fourths of adults with diabetes have hypertension
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Examples of the American Diabetes Associations Nutrition Recommendations for the Treatment and Prevention of Diabetes and Related Complications RECOMMENDATIONS CARBOHYDRATE Foods containing carbohydrate from whole grain, fruits, vegetables and low-fat milk are important components and should be included in
a healthy diet With regard to the glycemic effects of carbohydrate, the total amount of carbohydrate in meals or snacks is more important than the source or type As sucrose does not increase glycemia to a greater extent than isocaloric amounts of starch, sucrose and sucrose-containing foods do not need to be restricted by individuals with diabetes; however, they should be substituted for other carbohydrate sources or, if added, covered with insulin or other glucose-lowering medication As with the general public, consumption of dietary fiber is to be encouraged; however, there is no reason to recommend that individuals with diabetes consume a greater amount of fiber than other Americans PROTEIN In individuals with controlled type 2 diabetes, ingested protein does not increase plasma glucose concentrations, although ingested protein is just as potent a stimulant of insulin secretion as carbohydrate For individuals with diabetes, there is no evidence to suggest that usual protein intake 15 to 20 of total daily energy should be modified if renal function is normal FAT In all, 10 of energy intake should be derived from saturated fats Some individuals ie, those with LDL cholesterol 100
mg/dl may benefit from lowering saturated fat intake to 10 of energy intake To lower LDL cholesterol when weight loss is also desired, replace saturated fat with carbohydrate When weight loss is not needed, replace saturated fat with monounsaturated fat ENERGY BALANCE AND OBESITY In insulin-resistant individuals, reduced energy intake and modest weight loss improve insulin resistance and glycemia in the short term Structured programs that emphasize lifestyle changes, including education, reduced fat 30 of daily energy and energy intake, regular physical activity and regular participant contact, can produce long-term weight loss on the order of 5 to 7 of starting weight PREVENTION Structured programs that emphasize lifestyle changes, including education, reduced fat and energy intake, regular physical activity and regular participant contact, can produce long-term weight loss of 5 to 7 of starting weight and reduce the risk of developing diabetes All individuals, especially family members of individuals with type 2 diabetes, should be encouraged to engage in regular physical activity to decrease the risk of developing type 2 diabetes A A A A B B E A A A GRADING
B
B
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PREVENTION
OF TYPE 2 DIABETES There is substantial evidence that type 2 diabetes can be prevented or delayed through lifestyle changes,16 including modest weight loss if needed, increased physical activity, decreased consumption of dietary fat and energy and increased intake of whole-grain foods and dietary fiber21,22 For individuals at risk for diabetes, the goal of nutrition therapy is to decrease the likelihood of developing diabetes by encouraging physical activity and food choices to promote moderate weight loss or, at the very least, prevent further weight gain21 Lifestyle Modification Obesity is associated with an increased risk of type 2 diabetes Unfortunately, losing weight is difficult for many individuals and maintaining weight loss is even more difficult22 However, a number of recent studies have shown that moderate, sustained weight loss can substantially reduce the risk of type 2 diabetes A 37 lower risk of diabetes was found in the Framingham study group among individuals who sustained weight loss over two consecutive 8-year periods However, individuals who regained the lost weight did not experience any reduction in the incidence of diabetes24 Eriksson and Lindgarde in the
Malmo Feasibility Study showed that both weight loss and increased physical fitness were linked to a reduction in diabetes among participants in a lifestyle intervention group25 Interventions using diet alone, exercise alone, or diet and exercise combined all reduced the incidence of diabetes compared to a control group in the Da Qing Study26 Two other studies that used lifestyle modification and the medication orlistat 27 or lifestyle modification and bariatric surgery28 to lose weight also showed reduced risk of type 2 diabetes The Finnish Diabetes Prevention Study29 and the Diabetes Prevention Program DPP30 were designed to evaluate whether lifestyle modifications could prevent diabetes among individuals at high risk for diabetes because of impaired glucose tolerance The Finnish Diabetes Prevention Study used intensive lifestyle interventions, including weight reduction of 5 or more, reduction of total and saturated fat to less than 30 of
calories and less than 10 of calories, respectively, increased fiber 15 grams per 1,000 calories and increased physical activity to 4 or more hours per week29 On average, achievement of intervention goals ranged from 86 for exercise to 25 for
fiber consumption After 4 years, the overall risk of diabetes was reduced by 58 in the intervention group, an outcome that the researchers attributed specifically to changes in participants lifestyles The DPP was a 27-center clinical trial with 45 of participants from ethnic and racial minorities This study was designed to determine whether intensive lifestyle interventions or use of a pharmacological agent metformin to achieve weight loss would delay or prevent the onset of diabetes30 The pharmacological intervention included either metformin 850 mg per day for 4 weeks and 850 mg twice a day after 4 weeks or a placebo Diabetes risk was reduced by 31 in the metformin group Surprisingly, risk reduction for subjects in the lifestyle intervention group was even greater than the reduction caused by metformin Also, unlike the lifestyle intervention which was successful among all groups, metformin was ineffective in some groups, including older individuals and individuals who were only slightly overweight30 Based on the findings from these two trials, both the lifestyle and medication interventions were highly successful The American Diabetes Association and NIDDK recommend that
lifestyle modifications modest weight loss 5 to 10 of body weight and modest physical activity 30 minutes daily should be the first line of defense to prevent or delay the onset of type 2 diabetes16 Physical Activity Independent of its effect on energy balance, a low level of physical activity is a risk factor for type 2 diabetes21, 22 An active lifestyle has been shown in numerous prospective studies to prevent or delay the development of type 2 diabetes31-35 Moderate-intensity activities, such as brisk walking, as well as vigorous physical activities, appear to provide this protective effect Additionally, Kohl et al36 found that in middle-aged men, physical activity may provide some protection against mortality at all levels
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of glucose tolerance A large prospective study by Lee et al37 showed no elevated mortality risk in obese men if they were physically fit Among lean male subjects, there was only increased longevity if the men were also physically fit Increasing physical activity can help improve insulin sensitivity and may also improve cardiovascular health21, 22 Recognizing that both moderate and vigorous exercise decrease the risk of impaired glucose tolerance and can
help prevent or delay onset of type 2 diabetes, the American Diabetes Association recommends that everyone engage in regular physical activity to decrease the risk of developing type 2 diabetes21, 22 TREATMENT OF TYPE 2 DIABETES Although there are many similarities, treatment for individuals with type 2 diabetes differs in some respects from the recommendations for prevention However, basic to both prevention and treatment is the recommendation that individuals achieve optimal nutrition through healthy food choices and a physically active lifestyle21, 22 As individuals move from being insulin resistant to insulin deficient and diagnosed with type 2 diabetes, the therapeutic focus shifts from emphasizing weight loss to glucose control Although moderate weight loss may be beneficial for some individuals with type 2 diabetes, for most it is often too late for weight loss to improve health dramatically At later stages of the disease, medications including insulin often need to be combined with nutrition therapy and physical activity to achieve good metabolic control and decrease the incidence of chronic complications Many individuals with type 2 diabetes also have dyslipidemia and
hypertension, so decreasing intake of saturated fat, cholesterol and sodium should be a priority, as well as other lifestyle strategies as necessary to improve health The American Diabetes Association recommends that these strategies be implemented as soon as the diagnosis of diabetes is made, in order to prevent and treat the chronic complications of diabetes21, 22 Because increased physical activity can improve glycemia, decrease insulin resistance and reduce cardiovascular risk factors, it is recommended for individuals with type 2 diabetes21
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Energy Balance Because excess body weight decreases the effectiveness of insulin, weight loss is often a goal for clients with type 2 diabetes Several shortterm studies have shown that weight loss results in decreased insulin resistance, improved glycemia, reduced serum lipids and lower blood pressure38-40 Participants in the United Kingdom Prospective Diabetes Study who received 3 months of intensive diabetes nutrition therapy showed a 2 reduction in A1c and a 5 loss in weight41 The initial glucose response was primarily related to decreased energy intake, with the reduction in body weight a secondary response Fasting plasma glucose
levels of 100 mg/dl were maintained only in individuals who continued a restricted energy intake When caloric intake increased, fasting plasma glucose levels rose also, even when weight loss was maintained Structured programs that emphasize lifestyle changes, including education, reduced fat 30 of daily calories and energy intake, regular physical activity and regular participant contact, can produce long-term weight loss of 5 to 7 of starting weight29, 30, 42 Exercise and other behavior modification methods have been shown to be important adjuncts to diet-related weight-loss strategies Exercise can also help improve insulin sensitivity, decrease insulin resistance,43,44 lower blood glucose45 and potentially improve cardiovascular status46 In men with type 2 diabetes, increased physical activity may also independently reduce the risk of premature mortality47 Although exercise by itself has only a modest effect on weight loss,48 it is a useful adjunct to dietary modification Moreover, exercise has proven important in long-term maintenance of weight loss49, 50 The Look AHEAD Action for Health in Diabetes trial is currently recruiting volunteers aged 55 to 75 who are overweight or
obese and have type 2 diabetes This multicenter trial will examine the effects of weight loss achieved through an intense diet and exercise program The goal of the trial is to determine if weight loss reduces the occurrence of cardiovascular complications related to type 2 diabetes51
Carbohydrate As with the general population, research supports the importance of including carbohydrate-containing foods whole grains, fruits, vegetables and low-fat milk in the diet for individuals with type 2 diabetes21, 22 Determining the total amount of carbohydrate should be the first priority when developing nutrition plans for individuals with type 2 diabetes The total amount of carbohydrate recommended should be based on the individuals food and nutrition assessment In individuals with type 2 diabetes, research shows no longterm differences in glucose, lipid or insulin responses when food is either consumed at three main meals or divided into smaller meals and snacks, so food intake frequency should be based on individual preferences52, 53 As with pre-diabetes, dietary modifications should be based on prioritizing metabolic problems54 It is important to teach individuals with type 2 diabetes
what types of food contain carbohydrate such as starches, fruits, starchy vegetables, milk and sweets, appropriate portion sizes and the number of servings recommended for meals or snacks22 Carbohydrates effect on blood glucose and plasma lipids depends on the severity of the clients glucose intolerance55 By having clients record pre- and post-meal blood glucose levels, adjustments in food or meal planning or the addition of medications can be made as necessary21, 22 When individuals with type 2 diabetes require insulin, the consistency in carbohydrate content and the timing of meals become critical22 However, newer insulin dosing regimens allow for a greater variety of food choices and a more flexible lifestyle The total amount of carbohydrate in a meal or snack is more important than the type and source of carbohydrate21,22 Individuals who take insulin should adjust their pre-meal insulin doses based on the carbohydrate content of their meal21, 22 Fiber recommendations for individuals with type 2 diabetes are the same as for the general public: 38 grams and 25 grams for men and women 50 years and younger, respectively, and 30 grams and 21 grams for men and women over age 50,
respectively56 In a few studies, large amounts of dietary fiber about 50 grams per day have shown beneficial effects on insulinemia,
glycemia and lipemia, but it is unknown whether this intake level can be maintained over the long term21 Therefore, the American Diabetes Association maintains that there is no reason to recommend that individuals with diabetes consume more fiber than the amount recommended for the general population21, 22 Although it was once recommended that added sugars be avoided and naturally occurring sugars be restricted for individuals with diabetes, there is no scientific basis for these recommendations Dietary sucrose does not increase glycemia any more than isocaloric amounts of starch21, 22 While individuals with diabetes need not restrict sucrose and sucrose-containing foods due to concerns about aggravating hyperglycemia, if sucrose is included in a meal, it should be substituted for other carbohydrate sources If sucrose-containing foods are added to a meal, insulin or other medications need to be adjusted accordingly Sucrose and sucrosecontaining foods should be eaten in moderation in the context of a healthy diet Other food ingredients and nutrients
in a sucrose-containing food, such as fat, should be considered when making food choices Protein Average protein intake in the US is about 15 to 20 of calories and this level is consistent across all age groups, both in individuals with and without diabetes21, 22 Studies in healthy subjects of normal weight57 and subjects with controlled type 2 diabetes58-60 have shown that protein intake does not increase plasma glucose concentration, although protein is similar to carbohydrate in its potency as a stimulant of insulin secretion It has also been shown that protein does not slow postprandial absorption of carbohydrate57-59 Contrary to the advice often given to patients, available data regarding protein and diabetes suggest the following22: Dietary protein does not slow the absorption of carbohydrate Dietary protein and carbohydrate do not raise plasma glucose concentration later than carbohydrate alone and therefore do not prevent late-onset hypoglycemia
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For individuals with diabetes, there is no evide 
nce to suggest that usual protein intake 15 to 20 of total calories should be different, providing renal function is normal21,22 For some clients, especially those with less than
optimal glycemic control, the protein requirement may be greater than the RDA recommends 08 g/kg body weight, but not more than usual intake21, 22 Recent research has examined the role of branched-chain amino acids particularly leucine in metabolic regulation, including the glucose-alanine and insulin-signaling pathways, which influence both glucose homeostasis and protein turnover, particularly during weight loss Layman and colleagues examined weight loss and metabolic response among middleaged women on diets with ratios of carbohydrate/protein of either 35 or 15 protein intakes of 08 or 15 g/kg body weight After 16 weeks, subjects consuming the higher level of protein lost significantly more weight 216 vs 148 lbs and body fat 194 vs 123 lbs and less lean body mass -09 vs -24 lbs than those eating the higher carbohydrate diets61 The researchers concluded that a moderate increase in high-quality dietary protein with a corresponding reduction in carbohydrate can improve glucose and insulin homeostasis during weight loss62 The research suggests that branched-chain amino acids, particularly leucine, explain proteins beneficial effect on weight loss and insulin homeostasis The
long-term effects of diets high in protein and low in carbohydrate are unknown21, 22 Although higher protein diets may provide short-term weight loss and improved glycemia, there is no evidence to date that this weight loss is maintained Additionally, there is concern over the long-term safety effects of such diets, particularly their potential effect on LDL cholesterol levels if the protein source is not a lower fat option21, 22 A recent review of lowcarbohydrate diets concluded that the evidence is insufficient to either recommend or discourage low-carbohydrate diets Most importantly, the research to date shows that weight loss on low-carbohydrate diets is due to decreased total calories, not reduced carbohydrate content63 Additional research on the role of protein in weight loss will assist health professionals as
their clients seek effective solutions for reaching and maintaining a healthy weight Dietary Fat Dietary fat recommendations for clients with type 2 diabetes should be individualized and consider ethnic and cultural backgrounds, while at the same time adhering to the following recommendations22: Saturated fat less than 7 to 10 of calories Cholesterol less than 200
to 300 mg/day Polyunsaturated fat about 10 of caloric intake Trans-fatty acids minimal intake Compared to diets high in saturated fat, those high in either monounsaturated fat64-68 or low in fat and high in carbohydrate69-71 improve glucose tolerance and lipid profiles, particularly LDL cholesterol There is a concern that when diets high in monounsaturated fat are consumed, energy intake may increase, resulting in weight gain However, research shows that in individuals with type 2 diabetes who are able to maintain their weight, replacing carbohydrate with monounsaturated fat can help reduce postprandial glycemia and triglyceridemia64, 72 Diets high in monounsaturated fat may also reduce insulin resistance,66 although total fat may be associated with insulin resistance72, 73 Expert consensus suggests that, taken together, carbohydrate and monounsaturated fat should provide 60 to 70 of total calories The dietary ratio of carbohydrate to monounsaturated fat should be tailored to an individuals energy intake, weight, metabolic profile and treatment goals21, 22 For a client whose first priority is to lose weight, a diet higher in carbohydrate and lower in monounsaturated fat ie, 55
carbohydrate/15 monounsaturated fat may be appropriate For a client with high triglyceride levels, a diet lower in carbohydrate and higher in monounsaturated fat ie, 40 carbohydrate/30 monounsaturated fat may be beneficial More research is needed to examine the effect of polyunsaturated fats in diabetes therapy Compared to saturated fats, polyunsaturated fats lower LDL and total cholesterol levels, but
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not to the same extent as monounsaturated fats21 Since trans-unsaturated fatty acids lower HDL and raise LDL cholesterol levels, transfatty acid intake should be limited21 Alcohol In nutrition therapy for type 2 diabetes, the same precautions extended to the general population apply22 For individuals who choose to drink alcohol, daily intake should be limited to one drink per day for women and two for men74 One drink is defined as 12 ounces of beer, 5 ounces of wine or 11/2 ounces of distilled spirits21 The type of alcohol beer, wine or distilled spirits does not make a difference Individuals with medical conditions such as pancreatitis, neuropathy and severe hypertriglyceridemia or alcohol abuse should not drink, nor should women who are pregnant21, 22 Depending on the amount
of alcohol, whether it is consumed with or without food, and if alcohol use is excessive or chronic, individuals with diabetes may experience either hypoglycemic or hyperglycemic effects 21, 22 To reduce the risk of hypoglycemia, alcohol should be consumed with food When moderate amounts of alcohol are consumed with food, blood glucose and insulin levels are not affected21,22 Alcoholic beverages should be considered an addition to the regular meal plan for all individuals with diabetes22 MEAL PLANNING TOOLS Diabetes Food Pyramid The Diabetes Food Pyramid may be used as a tool for planning meals and snacks to help manage diabetes75 It is similar to USDAs Food Guide Pyramid, but it has been modified to more specifically address the needs of a diabetes meal and snack plan, such as identifying carbohydrate-containing foods For example, the base of the Diabetes Food Pyramid includes starchy vegetables such as potatoes and corn and legumes along with grain products The Meat, Meat Substitutes and Other Proteins Group includes cheese, in addition to meat, poultry and fish
Copyright 2003 American Diabetes Association Reprinted with permission from The American Diabetes Association
A range
of servings is provided for each food group, and amounts should be determined based on individual calorie needs Portion sizes should be emphasized when teaching individuals how to use the Diabetes Food Pyramid Carbohydrate Counting Carbohydrate counting is a flexible tool that focuses on the total amount of carbohydrate, rather than the source, eaten in consistent amounts at meals and snacks By paying careful attention to carbohydrate amount and distribution, blood glucose levels can be tightly controlled A consistent intake of carbohydrate minimizes blood glucose variations and also facilitates insulin adjustments76, 77 Exchange Lists Exchange lists are also used to provide guidance in meal planning78 The Exchange Lists for Meal Planning divides food into three groups: Carbohydrate group: starch, fruit, milk and other carbohydrate and vegetable lists This grouping allows for more flexibility in choosing carbohydrate sources
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Meat and meat substitutes group: very lean, lean, medium-fat and high-fat meat and meat substitutes lists Fat group: monounsaturated, polyunsaturated and saturated fat lists Updated tools for teaching carbohydrate counting and exchange lists for meal
planning are available through the American Diabetes Association wwwdiabetesorg and the American Dietetic Association wwweatrightorg Web sites STRATEGIES FOR COUNSELING AND EDUCATION Adherence to diabetic recommendations for nutrition and physical activity is challenging79 A vital role for the nutrition counselor is not only to provide information, but also to help the client follow long-term, health-promoting behaviors A client-centered, empowered approach to nutrition therapy requires client involvement developing a plan tailored to individual needs and preferences Diabetes nutrition education typically blends client-centered and traditional counseling practices79 Health professionals can encourage clients to make changes by providing options that fit into their lifestyle Dietary advice and counseling suggestions should always match an individuals readiness to change The role of the health professional in diabetes education should be to motivate and encourage ownership of change by the client Counseling suggestions include: Compare current eating habits with goals for the client, such as decreasing fat or calories Provide non-judgmental feedback on the dietary assessment
Ideally, the clients will help evaluate their own eating and exercise habits and provide suggestions regarding changes they are willing to make, such as cutting back on snack foods high in fat or walking 10 minutes every day Assess how ready the client is to make a change If he or she seems ambivalent, this should be discussed Encourage the client to work on a few changes at a time Some individuals may be willing to make only small changes at first, while others may be more willing to make bigger changes
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Discuss long-term goals with the client and provide realistic feedback For example, for clients who need to lose weight, encourage them to aim for a 5 reduction in weight over the course of a few months Help the client determine smaller, achievable daily goals Encourage small changes, self-monitoring of progress and recognition of success Employ strategies for enhancing behavioral change These may include recording food intake in a diary to increase awareness, modifying environmental cues that encourage overeating, using non-food rewards to promote continued success and using cognitive strategies to change mindset for target behaviors Contact and scheduled follow-up with
the patient will help provide guidance during setbacks or difficult situations A PLACE FOR PORK IN A DIABETIC DIET Unfortunately, many Americans are not aware that pork is 31 lower in fat, 29 lower in saturated fat and 14 lower in calories compared to 20 years ago80 The current USDA database for pork is supported by research confirming that the total fat, saturated fat, cholesterol and calories of lean pork compare favorably to lean chicken81 Research has shown that it is unnecessary to substitute poultry or fish for lean red meat to achieve desirable blood lipid levels82, 83 When individuals were instructed to consume at least 80 of their meat intake on a cholesterol-lowering diet from either lean red meat classified as beef, veal or pork or lean white meat poultry and fish, nearly identical reductions were achieved in mean total cholesterol and LDL cholesterol, as well as similar increases in HDL cholesterol82, 83 In educating clients about effective weightloss strategies, pork provides a nutritious option with an average of 173 calories per 3-ounce cooked serving for the most popular cut, pork chops Clients can look for the word loin in the name for the leanest pork cuts, such
as pork tenderloin or sirloin chop As detailed in the chart below, pork tenderloin provides comparable fat and calories compared to a skinless chicken breast Seven other cuts of pork have less total fat than a skinless chicken thigh
EIGHT CUTS OF LEAN PORK COMPARED TO LEAN CHICKEN
Saturated Fat Total Fat Cholesterol Calories
Chicken breast Pork tenderloin Pork boneless sirloin chop Pork boneless loin roast Pork boneless top loin chop Pork loin chop Pork rib chop
09 g 14 g 19 g 22 g 23 g 25 g 25 g 29 g 30 g 26 g
31 g 41 g 57 g 61 g 66 g 69 g 70 g 83 g 86 g 93 g
72 67 78 67 68 70 73 69 70 81
140 139 164 169 173 171 168 184 182 178
Pork boneless sirloin roast Pork boneless rib roast Chicken thigh
Based on 3 ounces cooked meat, skinless or trimmed roasted broiled Source for pork and chicken data: USDA Nutrient Database for Standard Reference, Release 15 Nutrient Data Laboratory Homepage, wwwnalusdagov/fnic/foodcomp, Accessed January 2003
NUTRIENT PROFILE OF PORK Lean pork is packed with important nutrients, yet provides minimal fat, calories and sodium Fresh pork has about 60 milligrams of sodium per 3-ounce serving The following table shows the nutrient value of a 3-ounce
serving of pork tenderloin
Nutrient Daily Value Use in Body
Protein Iron Zinc Phosphorus Thiamin Niacin Vitamin B-12
48 7 15 22 53 20 33
Aids in muscle growth and repair Helps the body fight off infection Helps the body transport oxygen Helps the body fight off infection Enables body to use energy from food Helps transfer energy in cells Strengthens bones Enables body to use energy from food Enables body to use energy from food Contributes to the health of skin Helps with formation of blood cells Enables body to use energy from food
Daily Value based on a 2,000-calorie diet
ONLINE RESOURCES
American Diabetes Association: wwwdiabetesorg Diabetes Forecast magazine: wwwdiabetesorg/diabetesforecast American Dietetic Association: wwweatrightorg Medical nutrition therapy evidence-based guides for practice: nutrition practice guidelines for type 1 and type 2 diabetes mellitus Available for order at: wwweatrightorg/pubs National Institute of Diabetes and Digestive and Kidney Diseases: wwwniddknihgov National Diabetes Education Program at the National Institutes of Health: wwwndepnihgov
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REFERENCES
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risk factors, 2001 JAMA 289:76-79, 2003 2 Centers for Disease Control and Prevention National Diabetes Fact Sheet General Information and National Estimates on Diabetes in the United States, 2000 Atlanta, Ga: US Department of Health and Human Services, Centers for Disease Control and Prevention; 2002 3 NIDDK/NIH Press release HHS launches first national diabetes prevention campaign 11/20/02 Found at: wwwniddknihgov/welcome/releaseshtm 4 Ford ES, et al Prevalence of metabolic syndrome among US adults Findings from the Third National Health and Nutrition Examination Survey JAMA 16:356-359, 2002 5 Boyle JP, et al Projection of diabetes burden through 2050: impact of changing demography and disease prevalence in the US Diabetes Care 2411:1936-1940, 2001 6 Hogan P, et al Economic costs of diabetes in the US in 2002 Diabetes Care 263:917-932, 2003 7 American Diabetes Association Basic Diabetes Information Found at: wwwdiabetesorg/main/info/facts/facts_natljsp 8 Sinha R, et al Prevalence of impaired glucose tolerance among children and adolescents with marked obesity N Engl J Med 34611:802-810, 2002 9 Yki-Jarvinen H Acute and chronic effects of hyperglycemia on glucose metabolism,
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mellitus on plasma concentrations of glucose, non-esterified fatty acid, and insulin during oral glucose tolerance tests Lancet i:790-794, 1963 71 Yu-Poth S, et al Effects of the National Cholesterol Education Programs Step I and Step II dietary intervention programs of cardiovascular disease risk factors: a meta-analysis Am J Clin Nutr 69:632-646, 1999 72 Garg A High monounsaturated diets for patients with diabetes mellitus: a meta-analysis Am J Clin Nutr 673:577S-582S, 1998 73 Mayer-Davis EJ, et al Dietary fat and insulin sensitivity in a tri-ethnic population: the role of obesity The Insulin Resistance Atherosclerosis Study Am J Clin Nutr 65:79-87, 1997 74 US Department of Agriculture, US Department of Health and Human Services Nutrition and Your Health: Dietary Guidelines for Americans 5th ed Home and Garden Bulletin No 232, 2000 75 American Dietetic Association and American Diabetes Association The First Step in Meal Planning Chicago and Alexandria, Va: American Dietetic Association and American Diabetes Association; 2003 76 American Dietetic Association and American Diabetes Association Basic Carbohydrate Counting Chicago and Alexandria, Va: American Dietetic Association and
American Diabetes Association; 2003 77 American Dietetic Association and American Diabetes Association Advanced Carbohydrate Counting Chicago and Alexandria, Va: American Dietetic Association and American Diabetes Association; 2003 78 American Dietetic Association and American Diabetes Association Exchange Lists for Meal Planning Chicago and Alexandria, Va: American Dietetic Association and American Diabetes Association; 2003 79 Maryniuk MD Counseling and education strategies for improved adherence to nutrition therapy In: American Diabetes Association Guide to Medical Nutrition Therapy for Diabetes ADA, 1999 80 Buege DR, et al A Nationwide Survey of the Composition and Marketing of Pork Products at Retail University of Wisconsin-Madison, Agricultural Bulletin R3509, 1990 81 Buege DR, et al A nationwide audit of the composition of pork and chicken cuts at retail J Food Composition Anal 113:249-261, 1998 82 Davidson MH, et al Comparison of the effects of lean red meat vs lean white meat on serum lipid levels among free-living persons with hypercholesterolemia Arch Intern Med 159:1331-1338, 1999 83 Hunninghake DB, et al Incorporation of lean red meat into a National Cholesterol
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FOR MORE INFORMATION ON DIABETES American Diabetes Association Information on how to prevent and control diabetes is available from the American Diabetes Association Web site at wwwdiabetesorg You may also e-mail questions to AskADA@diabetesorg or call the American Diabetes Association at 1-800-DIABETES 1-800-342-2383 American Diabetes Association ATTN: National Call Center 1701 North Beauregard Street Alexandria, VA 22311 National Pork Board Delicious, low-fat recipes are available through the National Pork Board at wwwporkandhealthorg National Pork Board PO Box 9114 Des Moines, IA 50306 515-223-2600
Source:upstate.edu
