Fat

In diabetes, the goals for fatty acids and dietary cholesterol are the same as for the general population. Cholesterol and saturated fat intake should be limited. Saturated fat is the primary determinant of LDL,7 and people with diabetes seem to be even more affected by dietary cholesterol than is the general population.8 Trans fats are similar to saturated fat in their effect on increasing LDL, and because they also have been shown to lower HDL, their intake should be limited as much as possible.9

Alcohol

Just as recommended for the general population, alcohol-containing drinks should be limited to two per day for men with diabetes and one per day for women with diabetes.10 When alcohol is consumed in moderation along with food, it has minimal effects on blood glucose and insulin levels.11 To prevent hypoglycemia, individuals using insulin or insulin secretagogues should always consume alcohol with food.4


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Type 1 diabetes

For patients with type 1 diabetes, the total amount of carbohydrate in meals and snacks is most important. This amount determines the premeal insulin dosage and the postprandial glucose response.12,13 It is most important for carbohydrate intake to be consistent when an individual is on a fixed insulin regimen and premeal adjustments are not made.2 There is also an association between improved blood-glucose control and insulin therapy with an undesired increase in body weight in type 1 diabetes. Because there is a risk that the increase in weight will negatively affect glycemia, lipids, BP control, and general state of health, weight gain should be prevented.14

Type 2 diabetes

Since most people with type 2 diabetes are both insulin-resistant and overweight, the focus of MNT should be on lifestyle changes to decrease energy intake and increase physical activity to boost energy expenditure.15-17 Intake of saturated fat, cholesterol, and sodium should also be limited, as many individuals with diabetes also have dyslipidemia and hypertension.18 Physical activity can increase blood-glucose control19 and lessen cardiovascular risk factors20 and insulin resistance.21,22 Patients can choose to eat three meals per day or eat multiple small meals and snacks.23,24 If insulin therapy or insulin secretagogues are used, meals should be at regular intervals and consistent in the amount of carbohydrate. A flexible insulin regimen allows food consumption to be flexible as well.4

Education of a newly diagnosed patient

Once the diagnosis of diabetes is made, the PCP should provide the patient with initial MNT guidelines for use until he or she is able to meet with an RD or attend a diabetes-education class. These guidelines should be presented in a simple and easy-to-understand manner (Table 3).

Ms. Szerlong, a registered and licensed dietitian, is a second-year student in the physician assistant program at Georgia Health Sciences University in Augusta, where Ms. Daitch is an associate professor and associate director of admissions, and Ms. Stallings is an assistant professor and director of admissions.

References

1. Centers for Disease Control and Prevention. 2011 National Diabetes Fact Sheet.

2. American Diabetes Association Task Force for Writing Nutrition Principles and Recommendations for the Management of Diabetes and Related Complications. American Diabetes Association position statement: evidence-based nutrition principles and recommendations for the treatment and prevention of diabetes and related complications. J Am Diet Assoc. 2002;102:109-118.

3. Schafer RG, Bohannon B, Franz MJ, et al. Diabetes nutrition recommendations for health care institutions. Diabetes Care. 2004;27 Suppl 1:S55-57.

4. Franz MJ, Bantle JP, Beebe CA, et al. Evidence-based nutrition principles and recommendations for the treatment and prevention of diabetes and related complications. Diabetes Care. 2002;25:148-198.

5. Franz MJ, Warshaw H, Daly AE, Green-Pastors J, Arnold MS, Bantle J. Evolution of diabetes medical nutrition therapy. Postgrad Med J. 2003;79:30-35. 

6. Gehling E. Medical nutrition therapy: an individualized approach to treating diabetes. Lippincotts Case Manag. 2001;6:2-9.

7. Hegsted DM, Ausman LM, Johnson JA, Dallal GE. Dietary fat and serum lipids: an evaluation of the experimental data. Am J Clin Nutr. 1993;57:875-883.

8. Hu FB, Stampfer MJ, Rimm EB, et al. A prospective study of egg consumption and risk of cardiovascular disease in men and women. JAMA. 1999;281:1387-1394. 

9. Judd JT, Clevidence BA, Muesing RA, et al. Dietary trans fatty acids: effects on plasma lipids and lipoproteins of healthy men and women. Am J Clin Nutr. 1994;59:861-868.

10. U.S. Department of Agriculture and Department of Health and Human Services. Dietary Guidelines for Americans, 5th ed. USDA; 2000. Home and Garden Bulletin No. 232:10-12.

11. Koivisto VA, Tulokas S, Toivonen M, et al. Alcohol with a meal has no adverse effects on postprandial glucose homeostasis in diabetic patients. Diabetes Care. 1993;16:1612-1614.

12. Rabasa-Lhoret R, Garon J, Langelier H, et al. Effects of meal carbohydrate content on insulin requirements in type 1 diabetic patients treated intensively with the basal-bolus (ultralente-regular) insulin regimen. Diabetes Care. 1999;22:667-673.

13. Heinemann L, Heise T, Wahl LC, et al. Prandial glycaemia after a carbohydrate-rich meal in type I diabetic patients: using the rapid acting insulin analogue [Lys(B28), Pro(B29)] human insulin. Diabet Med. 1996;13:625-629.

14. Purnell JQ, Hokanson JE, Marcovina SM, et al. Effect of excessive weight gain with intensive therapy of type 1 diabetes on lipid levels and blood pressure: results from the DCCT. Diabetes Control and Complications Trial. JAMA. 1998;280:140-146.

15. Wing RR, Blair EH, Bononi P, et al. Caloric restriction per se is a significant factor in improvements in glycemic control and insulin sensitivity during weight loss in obese NIDDM patients. Diabetes Care. 1994;17:30-36.

16. Kelley DE, Wing R, Buonocore C, et al. Relative effects of calorie restriction and weight loss in noninsulin-dependent diabetes mellitus. J Clin Endocrinol Metab. 1993;77:1287-12893.

17. Markovic TP, Jenkins AB, Campbell LV, et al. The determinants of glycemic responses to diet restriction and weight loss in obesity and NIDDM. Diabetes Care. 1998;21:687-694.

18. Barnard RJ, Jung T, Inkeles SB. Diet and exercise in the treatment of NIDDM. The need for early emphasis. Diabetes Care. 1994;17:1469-1472.

19. Schneider SH, Khachadurian AK, Amorosa LF, Clemow L, Ruderman NB. Ten-year experience with an exercise-based outpatient life-style modification program in the treatment of diabetes mellitus. Diabetes Care. 1992;15:1800-1810.

20. Hu FB, Stampfer MJ, Solomon C, et al. Physical activity and risk for cardiovascular events in diabetic women. Ann Intern Med. 2001;134:96-105.

21. Yamanouchi K, Shinozaki T, Chikada K, et al. Daily walking combined with diet therapy is a useful means for obese NIDDM patients not only to reduce body weight but also to improve insulin sensitivity. Diabetes Care. 1995;18:775-778.

22. Mayer-Davis EJ, D’Agostino R Jr, Karter AJ, et al. Intensity and amount of physical activity in relation to insulin sensitivity: the Insulin Resistance Atherosclerosis Study. JAMA. 1998;279:669-674. 

23. Arnold L, Mann JI, Ball MJ. Metabolic effects of alterations in meal frequency in type 2 diabetes. Diabetes Care. 1997;20:1651-1654.

24. Beebe CA, Van Cauter E, Shapiro ET, et al. Effect of temporal distribution of calories on diurnal patterns of glucose levels and insulin secretion in NIDDM. Diabetes Care. 1990;13:748-755.

All electronic documents accessed May 15, 2011.