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Artículos Científicos - 06/11/2013

DIABETES MANAGEMENT GUIDELINES

American Diabetes Association (ADA) Nutrition Guidelines for Adults With Diabetes

Recommendations 

  • Component of overall treatment for all with types 1 and 2 diabetes 
  • No “one-size-fits-all” eating approach 
    • Chosen eating pattern should improve glucose, BP, and lipid 
  • Individualized nutrition therapy, ideally provided by registered dietitian  

Type 1 

Flexible insulin therapy education program using carb counting 
meal planning 

Fixed-dose daily insulin 

Consistent carb intake (time, amount) 

   

Type 2 

Portion control, healthful food choices for literacy concerns, 
older adults 

  • DSME and support at diagnosis and thereafter  

 

  •  Overweight/obese adults with type 2 diabetes 
    •  For weight loss: reduce energy intake while maintaining healthful eating pattern 
    • Optimal macronutrient intake to reduce weight not established 

 

  • Modest weight loss may improve glycemia, BP, ± lipids 
    • Particularly early in disease process 

 

  • Recommended for modest weight loss 
    • Intensive lifestyle interventions: nutrition therapy counseling, physical activity, behavior change 
    • Ongoing support 

 

 

  • No ideal percentage of calories from carbohydrate, protein, or fat for individuals with diabetes 
  • Macronutrient distribution to be based on individualized assessment of 
    • Current eating patterns 
    • Preferences 
    • Metabolic goals 

 

 

  • Consider personal preferences and metabolic goals when recommending an 
    eating pattern. 

DASH 

High in fruits, vegetables, low-fat dairy, whole grains, poultry, fish, nuts. Low in saturated fat, red meat, sweets, sugar-containing beverages, sodium. 

Low carbohydrate 

Foods high in protein, fat; veggies low in carbs. 
Sugar-containing foods, grains avoided. 

Low fat 

Veggies, fruits, starches, lean protein, low-fat dairy.Total fat intake

Mediterranean style 

Abundant plant food, minimally processed, fresh, seasonal foods. Fruit as dessert; sugar/honey infrequently. Olive oil primary fat. Low to moderate dairy, eggs, red meat, wine (with meals).  

Vegan 

No flesh foods or animal products 

Vegetarian 

No flesh foods; includes eggs and/or dairy 

 

  • Develop collaborative goals with patient 
    • Ideal carb amount not established 

 

  • Amount of carbs and available insulin important factors influencing postprandial glycemic response; consider when developing eating plan 
  • Monitor carb intake to achieve glycemic control 
  • Carb intake from veggies, fruits, whole grains, legumes, dairy  
    • Avoid other carb sources, esp those with added fats, sugar, sodium 

 

  • Glycemic index and glycemic load 
    • Substitute foods with lower glycemic load for those with higher 
      load  
    • Modest improvement in glycemic control 

 

  • Dietary fiber and whole grains: consume at least  
    • Fiber: 25 g/day women; 38 g/day men (14 g fiber/1,000 kcals/day) 
    • ≥50% of all grains should be whole grains 

 

 

  • Minimize sucrose intake when substituting for starch 
    • Avoid displacing nutrient-dense foods 

 

  • Free fructose (naturally occurring) 
    • Potentially better glycemic control vs sucrose or starch 
    • Unlikely to impact TG if consumption is not excessive (>12% energy)  

 

  • Limit/avoid sugar-sweetened beverages 
    • Reduce risk for weight gain, worsening of cardiometabolic profile 

 

  • Nonnutritive and hypocaloric sweeteners 
    • Substitution for caloric sweeteners may reduce calorie, carb intake 

 

 

Diabetes without 
diabetic kidney disease 

  • No ideal intake to improve glycemic control or CVD risk  
  • Individualize goals 

 

Diabetes and macro- or microalbuminuria 

Reduction below usual intake not recommended 

Type 2 diabetes 

Do not use carb sources high in protein to treat or prevent hypoglycemia 

 

Total fat 

 

  • No ideal intake; individualize goals  
  • Fat quality more important than quantity 

 

Monounsaturated fatty acid  

  • Mediterranean-style, MUFA-rich eating pattern recommended as alternative to low-fat, 
    high carb in patients with type 2 diabetes 
  • May improve glycemic control, CVD risk factors 

 

Polyunsaturated fatty acid 

Limited evidence on effect in people with type 2 diabetes 

Dietary intake of fats 

Saturated fat 

 

Cholesterol 

 

Trans fat 

Limit as much as possible 

 

  • Omega-3 (EPA, DHA) supplements not recommended for CVD prevention or treatment 
  • Increase intake of foods with EPA, DHA, ALA 
    • Benefits on lipoproteins, CVD prevention, health outcomes 

 

  • Eat fish (particularly fatty fish) ≥2 times/week 

 

Vitamin or mineral supplementation: 
no benefit in patients without underlying deficiencies 

Antioxidants 
(vitamins E, C; carotene) 

Not advised due to lack of evidence of efficacy and concern re: long-term safety 

Micronutrients (chromium, magnesium, 
vitamin D) 

Insufficient evidence to recommend routine use to improve glycemic control in patients with diabetes 

Cinnamon 
Other herbs/supplements 

Insufficient evidence to support use for diabetes treatment 

Individualize meal planning: optimize food choices to meet 
recommended micronutrient dietary allowance/intake  

 

  • Daily moderation 
    • Women: ≤1 drink/day 
    • Men: ≤2 drinks/day  
    • 1 drink = 12 oz beer, 5 oz wine, 1.5 oz distilled spirits 

 

  • Alcohol consumption may increase risk for delayed hypoglycemia 
    • Especially if taking insulin, insulin secretagogues 
    • Educate on recognition, management of delayed hypoglycemia 

 

 

  • Reduce to 2,300 mg/day 
  • Patients with diabetes and hypertension 
    • Consider goal

 

 

  • Recommend portion control for weight loss, maintenance 
  • Know what foods contain carbs 
    • Starchy veggies, whole grains, fruit, milk/milk products, veggies, sugar 

 

  • Choose nutrient-dense, high fiber foods over processed foods 
  •  Avoid sugar-sweetened beverages 
  • Carb counting: usually no need to subtract fiber, sugar alcohols from total 
  • High trans, saturated fat foods: replace with foods high in unsaturated fats  
  • Choose lean protein and meat alternatives 
  • Vitamin and mineral supplements, herbal products, cinnamon not recommended to manage diabetes 
  • Moderate alcohol consumption 
  • Limit sodium intake to 2,300 mg/day 

 

Insulin secretagogues(sulfonylureas, meglitinides) 

  • Moderate carbohydrate amounts at each meal and snacks 
  • To reduce hypoglycemia risk:  
    • Eat carb source at each meal; do not skip meals 
    • Moderate carbohydrate amounts at each meal and snacks 
    • Carry carb source when doing physical activity