Nutritional principles in diabetes treatment as recommended by the American Diabetes Association (ADA)

12/05/2023

Lifestyle and diet adjustment is the top priority treatment method for people with diabetes. This is also the most challenging part of treatment planning as there is no one-fits-all diet, so meal planning should be individualized.

Nutritional therapy plays an integral role in the overall management of diabetes and each person with diabetes should be actively involved in education, self-management, and treatment planning including collaborative development of personal eating plan with experts and nutritionists. Below are some principles and goals to achieve at each meal, along with recommendations for a properly balanced diet for people with diabetes.

Goals need to be achieved each meal

Balanced, sufficient nutrition: Many patients misunderstand that diet control for diabetes means strict abstinence, especially cutting all carbohydrates out of the diet, having less and insufficient food causing nutrient deficiency, which makes the disease even worse. On the other hand, some patients rely on medication and do not control their diet, leading to obesity and increased risk of diseases such as hypertension and dyslipidemia.

Besides, some diabetes treatment drugs still have certain side effects. Therefore, appropriate diet control is a top priority in diabetes treatment. A balanced and complete diet provides enough energy, protein, carbohydrates, fats and micronutrients appropriate to age, nutritional status, metabolic needs, medical conditions, eating habits and lifestyle of the patient.

A balanced diet provides enough energy and nutrients and suitable for the lifestyle and medical condition of diabetic patients. (Photo: Freepik)

A balanced diet provides enough energy and nutrients and suitable for the lifestyle and medical condition of diabetic patients. (Photo: Freepik)

Avoid blood sugar spike after meals: After eating, a diabetic patient’s blood sugar will skyrocket. The American Diabetes Association (ADA) has recommended that blood sugar levels 1 – 2 hours after meals be kept below 180 mg/dl (10.0 mmol/L) Therefore, having right foods and distributing meals and snacks appropriately is the key to reducing post-meal blood sugar spikes.

Prevent hypoglycemia between meals: Hypoglycemia in diabetic patients occurs when blood sugar levels are less than < 70 mg/dL (3.9 mmol/L). Symptoms of hypoglycemia include tremors, irritability, confusion, rapid heartbeat and hunger, causing many inconveniences for diabetic patients. For patients whose blood sugar drops to <54 mg/dl, the patient may lose consciousness, convulsions, coma or even death. Causes of hypoglycemia in diabetic patients include insufficient food intake to compensate for physical activity, abuse of insulin and diabetes medication, or alcohol consumption. Therefore, nutritional planning for people with diabetes needs to focus on controlling and preventing hypoglycemia between meals..

Control and maintain an ideal weight: Overweight and obese patients are often at high risk of cardiovascular diseases and lipid disorders, while also increasing insulin resistance. Adipose tissue and fatty acids in the blood also increase the secretion of some hormones, reducing the effect of insulin. Therefore, overweight and obese patients need to have a gradual weight loss plan, consistent with the goal of losing 5-10% of body weight within 3-6 months until they reach their ideal weight and maintain it. On the contrary, for patients who are malnourished and have an inappropriate weight, the nutritional

American Diabetes Association Professional Practice Committee. 2. Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes-2022. Diabetes Care. 2022 Jan 1;45(Suppl 1):S17-S38.

Avoid blood sugar spike after meals: After eating, a diabetic patient’s blood sugar will skyrocket. The American Diabetes Association (ADA) has recommended that blood sugar levels 1 – 2 hours after meals be kept below 180 mg/dl (10.0 mmol/L). Therefore, having right foods and distributing meals and snacks appropriately is the key to reducing post-meal blood sugar spikes.

Prevent hypoglycemia between meals: Hypoglycemia in diabetic patients occurs when blood sugar levels are less than < 70 mg/dL (3.9 mmol/L). Symptoms of hypoglycemia include tremors, irritability, confusion, rapid heartbeat and hunger, causing many inconveniences for diabetic patients. For patients whose blood sugar drops to <54 mg/dl, the patient may lose consciousness, convulsions, coma or even death. Causes of hypoglycemia in diabetic patients include insufficient food intake to compensate for physical activity, abuse of insulin and diabetes medication, or alcohol consumption. Therefore, nutritional planning for people with diabetes needs to focus on controlling and preventing hypoglycemia between meals..

Control and maintain an ideal weight: Overweight and obese patients are often at high risk of cardiovascular diseases and lipid disorders, while also increasing insulin resistance. Adipose tissue and fatty acids in the blood also increase the secretion of some hormones, reducing the effect of insulin. Therefore, overweight and obese patients need to have a gradual weight loss plan, consistent with the goal of losing 5-10% of body weight within 3-6 months until they reach their ideal weight and maintain it. On the contrary, for patients who are malnourished and have an inappropriate weight, the nutritional

American Diabetes Association Professional Practice Committee. 2. Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes-2022. Diabetes Care. 2022 Jan 1;45(Suppl 1):S17-S38.

 A reasonable, nutritious diet helps people with diabetes avoid the risk of disease or dangerous complications (Photo: Freepik)

A reasonable, nutritious diet helps people with diabetes avoid the risk of disease or dangerous complications (Photo: Freepik)

2. Balanced and reasonable nutrition for people with diabetes

Energy

For patients with normal weight (not diagnosed with overweight or obesity), daily energy needs are about 25 – 30 kcal/kg body weight for light workers, 30 – 35 kcal/kg kg body weight for medium workers and 40 – 45 kcal/kg body weight for heavy workers.

For overweight and obese patients, the amount of energy needed will be lower but required 20 – 30 kcal/kg of ideal body weight per day.

The patient’s ideal weight is calculated according to the following formula:

Ideal weight = Height (m) x Height (m) x 22

Besides, energy-providing macronutrients need to be supplemented in the following proportions:

  • Protein: 15 – 20% of total energy
  • Carbohydrates: 50 – 60% of total energy
  • Fat: 20 -30% of total energy

Carbohydrates

A lot of people misunderstand that the diet for people with diabetes requires completely cutting out carbohydrates. In fact, patients still need to be provided with about 130g of carbohydrates per day, accounting for 50 – 60% of total daily energy intake. However, patients need to choose foods that provide carbohydrates with a moderate to low glycemic index.

Classification of foods based on hyperglycemic index:

High Moderate Low Very Low
≥ 70% 56 – 69% 40 – 55% ≤ 40%

Foods that are recommended to be used to supplement starch are foods high in fiber such as whole grains (brown rice, potatoes, rye bread), while limiting foods high in sugar. increase blood sugar quickly such as candy, white bread, sweet fruits such as jackfruit, papaya, mango, dried fruit, honey, etc. Patients can also consider using foods that use sugar systems with low glycemic index such as maltitol, isomalt, palatinose, stevia… to increase taste without causing post-meal blood sugar spikes.

Fat

Fat in the diet of people with diabetes requires attention and and consideration as it has a close relationship with the problem of lipid metabolism disorders.

Every day, patients need to supplement an amount of fat accounting for 20 – 25% of total dietary energy, note that saturated fat content should only account for less than 10% of total dietary energy and cholesterol in dietary supplements less than 300 mg per day. In particular, limit trans fat to less than 1% of total dietary energy. The recommended ratio of fat intake is as follows: saturated fat: Mono-unsaturated fatty acid (MUFA): Poly-unsaturated fatty acid – PUFA) = 1:1:1.

Patients should choose foods that provide protein but contain little saturated fat such as fish, or lean cuts of pork, beef, chicken, and plant-based protein sources such as tofu, peanuts, and sesame. You should use vegetable oils for frying as animal fats contain a lot of saturated fat. Foods that contain a lot of cholesterol and saturated fat should also be limited, such as fatty meat, animal organs, palm oil, coconut oil, margarine, shortening or foods that are deep fried, processed with used oil at high temperatures as they contain a lot of trans fat.

Besides, patients also need to supplement fats that are beneficial for the heart such as MUFA, PUFA, Omega 3. In particular, the effect of reducing bad cholesterol levels (LDL cholesterol) of MUFA and PUFA fats has been proven by recognized by the European Food Safety Authority. In addition, a clinical study by Paniagua and colleagues published in the Journal of the American College of Nutrition showed that a diet rich in MUFA helps diabetics improve insulin resistance and limit sugar spikes after meal. In a comprehensive study by Skerrett and colleagues in The European Journal of Preventive Cardiology also showed the benefits of consuming fish oil, a rich source of Omega 3, to help reduce the risk of stroke[1]. Patients can supplement foods rich in MUFA, PUFA and Omega 3 such as olive oil, fish oil, nuts such as almonds, cashews, pistachios… in their diet, especially for people with lipid metabolism disorders.

Skerrett PJ, Hennekens CH. Consumption of fish and fish oils and decreased risk of stroke. Prev Cardiol. 2003 Winter;6(1):38-41. doi: 10.1111/j.1520-037x.2003.00959.x. PMID: 12624561.

Bệnh nhân ĐTĐ nên chọn lựa, cân nhắc thực phẩm tiếp nạp kỹ lưỡng trong thực đơn dinh dưỡng (Ảnh: Freepik)

Diabetic patients should carefully choose and consider the foods they eat in their nutritional menu (Photo: Freepik)

Protein

For patients without kidney complications, they needs to be provided with 1 – 1.2 g protein/kg body weight per day. As for diseases with proteinuria or kidney failure, the amount of protein needed is 0.8 g/kg body weight per day. Patients should combine protein from animal and plant sources in their diet. Animal protein has complete and abundant essential amino acid content, but contains a lot of cholesterol and saturated fat. Meanwhile, plant protein, although the essential amino acid content is not as complete as animal protein, but easy to digest and not contain as much cholesterol as animal protein. Patients should supplement plenty of fish and seafood, skinless poultry, low-fat beef and pork, limit cholesterol-rich foods such as animal organs, and consume 2-4 eggs per week.

Fiber

The daily amount of fiber a patient needs to consume is about 20 – 30g. Fiber helps slow down the rate of digestion and slowly release glucose into the bloodstream by keeping food in the stomach longer and preventing digestive enzymes from acting on food. Besides, in addition to digestive effects such as reducing constipation and regulating bowel movements, fiber also helps reduce cholesterol and prevent atherosclerosis. A clinical study conducted at the Clinical Research Center in Dallas, USA, showed that a diet rich in fiber (50 g fiber/day with a ratio of soluble and insoluble fiber of 1:1 ) has the effect of improving blood sugar control, reducing blood lipids and reducing insulin secretion in people with diabetes. Supplementing soluble fibers such as FOS and Inulin has also been clinically proven to help reduce blood sugar indexes in people with type 2 diabetes and pre-diabetes. Therefore, patients need to focus on supplementing with lots of fiber from vegetables and fruits in the diet to limit post-meal blood sugar spikes and prevent cardiovascular risk factors..

Vitamins and Minerals

People with diabetes need to be fully supplemented with trace elements such as vitamins and minerals to maintain physiological functions in the body. To naturally supplement vitamins for the body, patients should choose to supplement fruits with a low glycemic index such as guava, apple, orange, pear, or a moderate amount of fruits with a medium glycemic index such as bananas, papayas, limit fruits with high glycemic index such as lychees, mangoes, watermelons, longans. You should consume fruit in whole pieces instead of squeezing fruit juice because the fiber in fruit helps reduce the rate of sugar absorption from fruit into the blood. In addition, patients should be given zinc supplementation.

There are several clinical studies summarized in the article: “Effects of zinc supplementation on diabetes mellitus: a systematic review and meta-analysis” shows that zinc supplementation is effective in controlling blood sugar and keeping blood lipid levels at healthy levels, reducing systolic and diastolic blood pressure. Zinc-rich foods that patients can supplement include meat, fish, seafood, and legumes…

Người bệnh ĐTĐ nên tiêu thụ hoa quả dưới dạng nguyên múi, nguyên miếng, giảm tốc độ hấp thụ đường từ hoa quả vào máu (Ảnh: Freepik)

People with diabetes should consume fruits in whole shapes, whole pieces to reduce the rate of sugar absorption from fruits into the blood. (Photo: Freepik)

Limit Salt  

The recommendation of salt intake per day is 5g. Consuming a lot of salt is related to high blood pressure, so patients need to limit foods that contain large amount of salt such as pickles, instant noodles, and processed meat products such as salted ham hocks and Salted pork leg, smoked meat, sausages, limit spices such as fish sauce during meal.

Limit alcohol

Alcohol and beer increase the risk of hypoglycemia, so diabetic patients are recommended to limit alcoholic beverages to 1 – 2 units of alcohol, equivalent to about 120 ml of wine, 300 ml of beer, or 30 ml of srong wine.

Meal arrangement

Ensuring a nutritious meal without suddenly increasing blood sugar after eating is a difficult balancing issue. Therefore, patients should divide foods into different meal throughout the day or add extra meals to supplement nutrition. For patients at risk of hypoglycemia in the late afternoon or midnight, patients can add a snack in the late afternoon or before going to bed with foods with a low glycemic index.

To ensure good quality of nutrition in the body, in addition to following a reasonable, nutritious diet, people with diabetes and pre-diabetes can also refer to specialized nutritional products such as Glucare Gold to help control blood sugar while improving health.

Glucare Gold contains the Glucare carbonhydrates system (Isomalt, Maltitol, Palatinose) with slow absorption and Chromium imported from the United States to help balance blood sugar for diabetics every day. In particular, the product has been clinically proven to have a low GI index, making it safe for diabetics. Glucare Gold nutritional products contain 38 essential nutrients such as high quality Protein, Omega 3, Omega 6, Vitamins and minerals to help improve health every day. The product is suitable for diabetics, and people at risk of diabetes. With 2 cups morning and evening, Glucare Gold helps balance blood sugar, improving daily health for patients.

Cần lưu ý bổ sung dinh dưỡng theo đúng nguyên tắc và khuyến nghị để cải thiện đường huyết, tăng cường sức khỏe ở bệnh nhân ĐTĐ (ảnh: Freepik)

It is necessary to pay attention to nutritional supplementation according to principles and recommendations to improve blood sugar and enhance health in diabetic patients. (Photo: Freepik)

Thus, nutrition is the most important issue in diabetes treatment with the purpose of ensuring adequate nutrition, balanced in quantity and quality to control blood sugar and maintain ideal weight and prevent dangerous developments and complications. Patients need to pay attention to their daily diet and at the same time be careful to the amount of intake nutrients to their body, ensuring sufficiency of essential nutrients and minimizing long-term complications.

REFERENCES:

  1. Bộ Y Tế, Quyết định 5481/QĐ-BYT VỀ VIỆC BAN HÀNH TÀI LIỆU CHUYÊN MÔN “HƯỚNG DẪN CHẨN ĐOÁN VÀ ĐIỀU TRỊ ĐÁI THÁO ĐƯỜNG TÍP 2”. 2020
  2. American Diabetes Association Professional Practice Committee. 2. Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes-2022. Diabetes Care. 2022 Jan 1;45(Suppl 1):S17-S38.
  3. American Diabetes Association. Economic costs of diabetes in the U.S. in 2017. Diabetes Care 2018;41:917–928
  4. EFSA (European Food Safety Authority),2011. Scientific Opinion on the substantiation of health claims related to the replacement of mixtures of saturated fatty acids (SFAs) as present in foods or diets with mixtures of monounsaturated fatty acids (MUFAs) and/or mixtures of polyunsaturated fatty acids (PUFAs),and maintenance of normal blood LDL-cholesterol concentrations (ID 621, 1190, 1203, 2906, 2910, 3065) pursuant to Article 13(1) of Regulation (EC) No 1924/2006.The EFSA Journal.
  5. Paniagua JA, de la Sacristana AG, Sánchez E, Romero I, Vidal-Puig A, Berral FJ, Escribano A, Moyano MJ, Peréz-Martinez P, López-Miranda J, Pérez-Jiménez F. A MUFA-rich diet improves postprandial glucose, lipid and GLP-1 responses in insulin-resistant subjects. J Am Coll Nutr. 2007 Oct;26(5):434-44. doi: 10.1080/07315724.2007.10719633. PMID: 17914131.
  6.  Skerrett PJ, Hennekens CH. Consumption of fish and fish oils and decreased risk of stroke. Prev Cardiol. 2003 Winter;6(1):38-41. doi: 10.1111/j.1520-037x.2003.00959.x. PMID: 12624561.
  7.  Chandalia M, Garg A, Lutjohann D, von Bergmann K, Grundy SM, Brinkley LJ. Beneficial effects of high dietary fiber intake in patients with type 2 diabetes mellitus. N Engl J Med. 2000 May 11;342(19):1392-8. doi: 10.1056/NEJM200005113421903. PMID: 10805824.
  8.  Wang L, Yang H, Huang H, Zhang C, Zuo HX, Xu P, Niu YM, Wu SS. Inulin-type fructans supplementation improves glycemic control for the prediabetes and type 2 diabetes populations: results from a GRADE-assessed systematic review and dose-response meta-analysis of 33 randomized controlled trials. J Transl Med. 2019 Dec 5;17(1):410. doi: 10.1186/s12967-019-02159-0. PMID: 31805963; PMCID: PMC6896694.
  9.  Jayawardena R, Ranasinghe P, Galappatthy P, Malkanthi R, Constantine G, Katulanda P. Effects of zinc supplementation on diabetes mellitus: a systematic review and meta-analysis. Diabetol Metab Syndr. 2012 Apr 19;4(1):13. doi: 10.1186/1758-5996-4-13. PMID: 22515411; PMCID: PMC3407731.
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