Nutrition Therapy Recommendations for the Management of Adults with Diabetes

25/07/2023

In October 2013, in the journal Diabetes Care, the American Diabetes Association (ADA) published nutrition therapy recommendations for diabetics, providing the most accurate advice on what patients should eat and how to eat when they have to face this disease.

Diabetes is a metabolic disorder that occurs when a patient has high levels of sugar (glucose) in the blood and exceeds the glomerular filtration rate, resulting in glucose in the urine.

People with diabetes will have to face many dangerous complications: vision loss, blindness, limb necrosis, diabetic coma, brain stroke, heart stroke… This is a consequence of uncontrolled long-term hyperglycemia, micronutrient deficiencies, damaging to cells at the microscopic level such as blood vessels.

Nearly 5 million Vietnamese people are suffering from diabetes

Nowadays, diabetes is a topical problem. According to the International Diabetes Federation (IDF), in 2021, 537 million people had to face diabetes, meaning that 1 in 10 adults who are 20-79 years old will have diabetes; 1 out of 6 babies born will be affected by gestational diabetes. In Vietnam, according to the survey results of the Ministry of Health, the prevalence of diabetes in adults is estimated at 7.1%, equivalent to about 5 million people with diabetes. It is expected that the number of diabetes cases worldwide in general and in Vietnam in particular will tend to continue to increase rapidly in the coming years.

Faced with many risks of dangerous complications, patients with diabetes need to learn and understand the basic principles to minimize the occurrence of complications. One of the most important keys is nutrition.

Bệnh lý Đái tháo đường đang ngày càng gia tăng trên toàn thế giới (Ảnh: Freepik)

The number of patients with diabetes is increasing worldwide (Photo: Freepik)

Below are nutrition recommendations from October 2013, researched and published by the American Diabetes Association (ADA). This is a non-profit organization based in the United States, working with the goal of providing knowledge about diabetes to the public, and contributing to helping people with diabetes by sponsoring research to find out more effective solutions for the prevention and treatment of this disease. The network of ADA recognizes the participation of 565,000 volunteers, with an academic community of 12,000 healthcare professionals, and more than 250 employees, ready to work towards the mission of “To prevent and cure diabetes and to improve the lives of all people affected by diabetes.

Thoroughly researched by the American Diabetes Association (ADA), these nutrition recommendations will help people with diabetes increase their knowledge of essential nutrients, while maintaining a reasonable diet. This will be a solid foundation for patients to stay healthy throughout the treatment process, strengthen resistance, limit complications and ensure stable sugar levels.

Goal of nutrition therapy recommendations for patients with diabetes

1) To promote and support healthful eating patterns, emphasizing a variety of nutrient dense foods in appropriate portion sizes

This is in order to improve overall health and specifically to: 

– Attain individualized glycemic, blood pressure, and lipid goals. General recommended goals from the ADA for these markers are as follows:

+ A1C <7%. (A1C, also known as hemoglobin A1C or HbA1c test, is a simple blood test that measures average blood sugar over 3 months)

+ Blood pressure <140/80 mmHg. 

+ LDL (low-density lipoprotein) cholesterol <100 mg/dL; triglycerides <150 mg/dL; HDL (high-density lipoprotein) cholesterol >40 mg/dL for men; HDL cholesterol >50 mg/dL for women.  

– Achieve and maintain body weight goals.  

– Delay or prevent complications of diabetes.

2) To address individual nutrition needs based on personal and cultural preferences, health literacy and numeracy, access to healthful food choices, willingness and ability to make behavioral changes, as well as barriers to change.

3) To maintain the pleasure of eating by providing positive messages about food choices while limiting food choices only when indicated by scientific evidence.

4) To provide the individual with diabetes with practical tools for day-to-day meal planning rather than focusing on individual macronutrients, micronutrients, or single foods.

Summary of nutrition therapy recommendations from the American Diabetes Association (ADA)

* Evidence Rating:

A – Clear evidence from well-conducted, generalizable randomized controlled trials that are adequately powered

B – Supportive evidence from well-conducted cohort studies 

C – Supportive evidence from poorly controlled or uncontrolled studies

D – Supportive evidence to support this condition not being considered during routine physical examination.

E – Expert consensus or clinical experience

 

Topic Recommendation Evidence rating
Effectiveness of nutrition therapy Nutrition therapy is recommended for all people with type 1 and type 2 diabetes as an effective component of the overall treatment plan. A
Individuals who have diabetes should receive individualized MNT as needed to achieve treatment goals, preferably provided by an RD familiar with the components of diabetes MNT. A
– For individuals with type 1 diabetes, participation in an intensive flexible insulin therapy education program using the carbohydrate counting meal planning approach can result in improved glycemic control. A
– For individuals using fixed daily insulin doses, consistent carbohydrate intake with respect to time and amount can result in improved glycemic control and reduce risk for hypoglycemia. B
– A simple diabetes meal planning approach such as portion control or healthful food choices may be better suited to individuals with type 2 diabetes identified with health and numeracy literacy concerns. This may also be an effective meal planning strategy for older adults. C
People with diabetes should receive DSME according to national standards and diabetes self-management support when their diabetes is diagnosed and as needed thereafter. B
Because diabetes nutrition therapy can result in cost savings (B) and improved outcomes such as reduction in A1C (A), nutrition therapy should be adequately reimbursed by insurance and other payers. (E) B, A, E
Energy balance For overweight or obese adults with type 2 diabetes, reducing energy intake while maintaining a healthful eating pattern is recommended to promote weight loss. A
Modest weight loss may provide clinical benefits (improved glycemia, blood pressure, and/or lipids) in some individuals with diabetes, especially those early in the disease process. To achieve modest weight loss, intensive lifestyle interventions (counseling about nutrition therapy, physical activity, and behavior change) with ongoing support are recommended. A
Optimal mix of macronutrients Evidence suggests that there is not an ideal percentage of calories from carbohydrate, protein, and fat for all people with diabetes (B); therefore, macronutrient distribution should be based on individualized assessment of current eating patterns, preferences, and metabolic goals. (E) B, E
Eating patterns A variety of eating patterns (combinations of different foods or food groups) are acceptable for the management of diabetes. Personal preferences (e.g., tradition, culture, religion, health beliefs and goals, economics) and metabolic goals should be considered when recommending one eating pattern over another. E
Carbohydrates Evidence is inconclusive for an ideal amount of carbohydrate intake for people with diabetes. Therefore, collaborative goals should be developed with the individual with diabetes. C
The amount of carbohydrates and available insulin may be the most important factor influencing glycemic response after eating and should be considered when developing the eating plan. A
Monitoring carbohydrate intake, whether by carbohydrate counting or experience-based estimation remains a key strategy in achieving glycemic control. B
For good health, carbohydrate intake from vegetables, fruits, whole grains, legumes, and dairy products should be advised over intake from other carbohydrate sources, especially those that contain added fats, sugars, or sodium. B
Glycemic index and glycemic load Substituting low–glycemic load foods for higher–glycemic load foods may modestly improve glycemic control. C
Dietary fiber and whole grains People with diabetes should consume at least the amount of fiber and whole grains recommended for the general public. C
Substitution of sucrose for starch While substituting sucrose-containing foods for isocaloric amounts of other carbohydrates may have similar blood glucose effects, consumption should be minimized to avoid displacing nutrient-dense food choices. A
Fructose Fructose consumed as “free fructose” (i.e., naturally occurring in foods such as fruit) may result in better glycemic control compared with isocaloric intake of sucrose or starch (B), and free fructose is not likely to have detrimental effects on triglycerides as long as intake is not excessive (>12% energy). (C) B, C
People with diabetes should limit or avoid intake of SSBs (from any caloric sweetener including high fructose corn syrup and sucrose) to reduce risk for weight gain and worsening of cardiometabolic risk profile. B
NNSs and hypocaloric sweeteners Use of NNSs has the potential to reduce overall calorie and carbohydrate intake if substituted for caloric sweeteners without compensation by intake of additional calories from other food sources. B
Protein For people with diabetes and no evidence of diabetic kidney disease, evidence is inconclusive to recommend an ideal amount of protein intake for optimizing glycemic control or improving one or more CVD risk measures; therefore, goals should be individualized. C
For people with diabetes and diabetic kidney disease (either micro- or macroalbuminuria), reducing the amount of dietary protein below usual intake is not recommended because it does not alter glycemic measures, cardiovascular risk measures, or the course of GFR decline. A
In individuals with type 2 diabetes, ingested protein appears to increase insulin response without increasing plasma glucose concentrations. Therefore, carbohydrate sources high in protein should not be used to treat or prevent hypoglycemia. B
Total fat Evidence is inconclusive for an ideal amount of total fat intake for people with diabetes; therefore, goals should be individualized (C); fat quality appears to be far more important than quantity. (B) C, B
MUFAs/PUFAs In people with type 2 diabetes, a Mediterranean-style, MUFA-rich eating pattern may benefit glycemic control and CVD risk factors and can therefore be recommended as an effective alternative to a lower-fat, higher-carbohydrate eating pattern. B
Omega-3 fatty acids Evidence does not support recommending omega-3 (EPA and DHA) supplements for people with diabetes for the prevention or treatment of cardiovascular events. A
As recommended for the general public, an increase in foods containing long-chain omega-3 fatty acids (EPA and DHA) (from fatty fish) and omega-3 linolenic acid (ALA) is recommended for individuals with diabetes because of their beneficial effects on lipoproteins, prevention of heart disease, and associations with positive health outcomes in observational studies. B
The recommendation for the general public to eat fish (particularly fatty fish) at least two times (two servings) per week is also appropriate for people with diabetes. B
Saturated fat, dietary cholesterol, and trans fat The amount of dietary saturated fat, cholesterol, and trans fat recommended for people with diabetes is the same as that recommended for the general population. C
Plant stanols and sterols Individuals with diabetes and dyslipidemia may be able to modestly reduce total and LDL cholesterol by consuming 1.6–3 g/day of plant stanols or sterols typically found in enriched foods. C
Micronutrients and herbal supplements There is no clear evidence of benefit from vitamin or mineral supplementation in people with diabetes who do not have underlying deficiencies. C
– Routine supplementation with antioxidants, such as vitamins E and C and carotene, is not advised because of lack of evidence of efficacy and concern related to long-term safety. A
– There is insufficient evidence to support the routine use of micronutrients such as chromium, magnesium, and vitamin D to improve glycemic control in people with diabetes C
–  There is insufficient evidence to support the use of cinnamon or other herbs/ supplements for the treatment of diabetes. C
It is recommended that individualized meal planning include optimization of food choices to meet recommended dietary allowance/dietary reference intake for all micronutrients. E
Alcohol If adults with diabetes choose to drink alcohol, they should be advised to do so in moderation (one drink per day or less for adult women and two drinks per day or less for adult men). E
Alcohol consumption may place people with diabetes at increased risk for delayed hypoglycemia, especially if taking insulin or insulin secretagogues. Education and awareness regarding the recognition and management of delayed hypoglycemia is warranted. C
Sodium The recommendation for the general population to reduce sodium to less than 2,300 mg/day is also appropriate for people with diabetes B
For individuals with both diabetes and hypertension, further reduction in sodium intake should be individualized. B

Summary of priority topics

1) Strategies for all people with diabetes

– Portion control should be recommended for weight loss and maintenance. 

– Carbohydrate-containing foods and beverages and endogenous insulin production are the greatest determinant of the postmeal blood glucose level; therefore, it is important to know what foods contain carbohydrates-starchy vegetables, whole grains, fruit, milk and milk products, vegetables, and sugar.

– When choosing carbohydrate-containing foods, choose nutrient-dense, high-fiber foods whenever possible instead of processed foods with added sodium, fat, and sugars. Nutrient-dense foods and beverages provide vitamins, minerals, and other healthful substances with relatively few calories. Calories have not been added to them from solid fats, sugars, or refined starches.

– Avoid SSBs.

– For most people, it is not necessary to subtract the amount of dietary fiber or sugar alcohols from total carbohydrates when carbohydrate counting. 

– Substitute foods higher in unsaturated fat (liquid oils) for foods higher in trans or saturated fat.

– Select leaner protein sources and meat alternatives. 

– Vitamin and mineral supplements, herbal products, or cinnamon to manage diabetes are not recommended due to lack of evidence. 

– Moderate alcohol consumption (one drink/day or less for adult women and two drinks or less for adult men) has minimal acute or long-term effects on blood glucose in people with diabetes. To reduce risk of hypoglycemia for individuals using insulin or insulin secretagogues, alcohol should be consumed with food.

– Limit sodium intake to 2,300 mg/day.

Người mắc đái tháo đường cần tuân thủ chế độ ăn nghiêm ngặt để bảo vệ sức khỏe (Ảnh: Freepik)

People with diabetes need to follow a strict diet to protect their health (Photo: Freepik)

2) Priority should be given to coordinating food with type of diabetes medicine for those individuals on medicine.

– For individuals who take insulin secretagogues: 

+ Moderate amounts of carbohydrate at each meal and snacks. 

+ To reduce risk of hypoglycemia:

  • Eat a source of carbohydrates at meals. 
  • Moderate amounts of carbohydrates at each meal and snacks. 
  • Do not skip meals. 
  • Physical activity may result in low blood glucose depending on when it is performed. Always carry a source of carbohydrates to reduce risk of hypoglycemia.

– For individuals who take biguanides (metformin):

+  Gradually titrate to minimize gastrointestinal side effects when initiating use:

  • Take medication with food or 15 min after a meal if symptoms persist. 
  • If side effects do not resolve over time (a few weeks), follow up with health care provider. 
  • If taking along with an insulin secretagogue or insulin, may experience hypoglycemia.

– For individuals who take a-glucosidase inhibitors: 

+ Gradually titrate to minimize gastrointestinal side effects when initiating use. 

+ Take at start of meal to have maximal effect: 

  •  If taking along with an insulin secretagogue or insulin, may experience hypoglycemia.
  •  If hypoglycemia occurs, eat something containing monosaccharides such as glucose tablets as drug will prevent the digestion of polysaccharides.

– For individuals who take incretin mimetics (GLP-1): 

+ Gradually titrate to minimize gastrointestinal side effects when initiating use: 

  • Injection of daily or twice-daily GLP-1s should be premeal. 
  • If side effects do not resolve over time (a few weeks), follow up with health care provider. 
  • If taking along with an insulin secretagogue or insulin, may experience hypoglycemia. 
  • Once-weekly GLP-1s can be taken at any time during the day regardless of meal times. 

– For individuals with type 1 diabetes and insulin-requiring type 2 diabetes: 

+ Learn how to count carbohydrates or use another meal planning approach to quantify carbohydrate intake. The objective of using such a meal planning approach is to “match” mealtime insulin to carbohydrates consumed. 

+ If on a multiple-daily injection plan or on an insulin pump: 

  • Take mealtime insulin before eating. 
  • Meals can be consumed at different times. 
  • If physical activity is performed within 1– 2 h of mealtime insulin injection, this dose may need to be lowered to reduce risk of hypoglycemia.

+ If on a premixed insulin plan: 

  • Insulin doses need to be taken at consistent times every day. 
  • Meals need to be consumed at similar times every day. 
  • Do not skip meals to reduce risk of hypoglycemia. 
  • Physical activity may result in low blood glucose depending on when it is performed. Always carry a source of quick-acting carbohydrates to reduce risk of hypoglycemia.

+ If on a fixed insulin plan: Eat similar amounts of carbohydrates each day to match the set doses of insulin.

Tuân thủ phác đồ điều trị từ bác sĩ, kết hợp với chế độ ăn lành mạnh để cải thiện sức khỏe cho người bệnh tiểu đường (Ảnh: Freepik)

Follow the treatment regimen from the doctor, combining with a healthy diet to improve the health of people with diabetes (Photo: Freepik)

Glucare Gold – Balance blood sugar, promote health every day

To meet nutrition therapy recommendations, people with diabetes need to have adequate knowledge and seriousness in controlling their daily diets. However, a strict diet makes most people with chronic diabetes prone to micronutrient deficiencies because they do not meet the recommended nutrition needs. This makes the body easily fall into a state of fatigue, numbness in the limbs, erratic blood sugar changes, increasing the risk of complications during the disease period. Glucare Gold is a specialized nutrition solution for people with diabetes to help control blood sugar and promote health.

With a formula based on nutrition recommendations for diabetics, Glucare Gold possesses a slow absorption of Glucare (Isomalt, Maltitol, Palatinose) and Chromium imported from the United States to help balance blood sugar for people with diabetes every day.

Glucare Gold has been clinically proven to have a low glycemic index to help stabilize blood sugar, safe for diabetics’ health. In particular, the product also adds 38 essential nutrients such as high-quality protein, Omega 3, Omega 6, vitamins and minerals, fully meeting the nutrition needs due to the daily deficiency of diabetics’ diets, helping patients improve their health.

Not only is it a nutrition product for diabetics, Glucare Gold is also a reasonable source of nutrition for people at risk of diabetes. With 2 cups in the morning and evening, Glucare Gold helps balance blood sugar and promote health every day. With outstanding advantages, in 2018, Glucare Gold was recognized by the Ministry of Industry and Trade of Vietnam as a product that achieved the National Brand of Medical Nutrition.

Conclusion

For people with diabetes, nutrition is an important factor to protect their health day after day. “Nutrition Therapy Recommendations for the Management of Adults with Diabetes” provided by the American Diabetes Association (ADA) brings an overview of the role of nutrition in the management of this dangerous disease. In addition, people with diabetes can refer to nutrition products that are clinically proven to have a low glycemic index such as Glucare Gold to supplement balanced nutrition and improve health every day.

Currently, the American Diabetes Association (ADA) has also updated the latest content related to “Standards of Care for Diabetes 2023”. For more detailed document information, please download the file below.

REFERENCES

  1. Evert, A. B., Boucher, J. L., Cypress, M., Dunbar, S. A., Franz, M. J., Mayer-Davis, E. J., … & Yancy Jr, W. S. (2014). Nutrition therapy recommendations for the management of adults with diabetes. Diabetes care, 37(Supplement_1), S120-S143.
  2. Hội Tim mạch học (2013). Tóm tắt khuyến cáo 10/2013 của Ada về điều trị dinh dưỡng cho bệnh nhân đái tháo đường.
  3. Bộ Y tế (2020). Để sống vui, khỏe với bệnh đái tháo đường.
  4. Bộ Y tế (2022). Khoảng 5 triệu người Việt đang mắc căn bệnh gây nhiều biến chứng về tim mạch, thần kinh, cắt cụt chi…
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