Recommendations Summary
DM: Protein and Diabetes 2008
Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.
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Recommendation(s)
DM: Protein Intake and Normal Renal Function
In persons with type 1 or type 2 diabetes with normal renal function, the RD should advise that usual protein intake of approximately 15 to 20% of daily energy intake does not need to be changed. Although protein has an acute effect on insulin secretion, usual protein intake in long-term studies has minimal effects on glucose, lipids, and insulin concentrations.
Rating: Fair
ConditionalDM: Protein Intake and Nephropathy
In persons with diabetic nephropathy, a protein intake of one gram or less per kg body weight per day is recommended. Diets with less than one gram protein per kg body weight per day have been shown to improve albuminuria in persons with nephropathy; however, they have not been shown to have significant effects on glomerular filtration rates (GFR).
Rating: Fair
ConditionalDM: Protein Intake and Late Stage Nephropathy
For persons with late stage diabetic nephropathy (Chronic Kidney Disease [CKD] Stages 3-5), hypoalbuminemia (an indicator of malnutrition) and energy intake must be monitored and changes in protein and energy intake made to correct deficits. A protein intake of approximately 0.7 grams per kg body weight per day has been associated with hypoalbuminemia, whereas a protein intake of approximately 0.9 grams per kg body weight per day has not.
Rating: Fair
Conditional-
Risks/Harms of Implementing This Recommendation
- Diets too low in protein and energy intakes can lead to hypoalbuminemia (malnutrition) and unintentional weight loss. This needs to be monitored in persons with diabetic nephropathy who are restricting protein intake and may have a diminished appetite.
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Conditions of Application
- In persons with diabetic nephropathy, hypoalbuminemia and weight must be monitored.
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Potential Costs Associated with Application
- Protein intake of approximately 0.6 g/kg/d or lower often requires purchase and use of low-protein foods. This can contribute to the cost of food.
- Although costs of MNT sessions and reimbursement vary, medical nutrition therapy sessions are essential for improved outcomes.
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Recommendation Narrative
- The amount of protein consumed at meals has minimal influence on
glycemic response, on lipids, on hormones and metabolites, and shows no long-term effect on insulin requirements. - Two single meal studies (Nordt et al, 1991; Gannon et al, 2001) report an acute insulin response to ingestion of protein.
- However, three studies (Luscombe et al, 2002; Parker et al, 2002; Gannon et al, 2003) based on higher protein diets (30% of energy from protein) lasting five to twelve weeks showed no significant difference in longer-term insulin response; one study (Gannon et al, 2003) showed a significant decrease in A1C.
- As the percentage of energy from protein is increased and the percentage of energy from fat remains constant, the percentage of energy from carbohydrate is decreased, and therefore it is difficult to determine whether higher protein intakes or lower carbohydrate intakes result in significant effects on metabolic outcomes.
- Six positive-quality randomized controlled trials based on lower protein diets in the management of diabetic nephropathy report inconclusive findings; in all six studies this may be a result of poor compliance with reduction in protein intake (Raal et al, 1994; Hansen et al, 1999; Hansen et al, 2002; Meloni et al, 2002; Pijls et al, 2002; Meloni et al, 2004).
- In the two studies that were able to compare protein levels greater than 1.0 g/kg/day with protein intakes of 0.8 g/kg/day or lower, the lower protein diets significantly improved albuminuria but had no significant effects on glomerular filtration rate (Hansen et al, 1999, Meloni et al, 2002).
- The other four studies found no significant difference between groups in either albumin excretion rate or glomerular filtration rate.
- In two studies, hypoalbuminemia was associated with an actual protein intake of ~0.7 g/kg/d (Meloni et al, 2002), but not at a protein intake of ~0.9 g/kg/day (Meloni et al, 2004).
- American Diabetes Association Recommendation: For individuals with diabetes and normal renal function, there is insufficient evidence to suggest that usual protein intake (15-20% of energy) should be modified (Grade E).
- The amount of protein consumed at meals has minimal influence on
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Recommendation Strength Rationale
- Conclusion Statements were given Grade II
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Minority Opinions
Consensus reached.
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Risks/Harms of Implementing This Recommendation
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Supporting Evidence
The recommendations were created from the evidence analysis on the following questions. To see detail of the evidence analysis, click the blue hyperlinks below (recommendations rated consensus will not have supporting evidence linked).
What is the relationship between protein intake and metabolic outcomes in persons with type 1 and type 2 diabetes?
What is the evidence that protein restriction (with or without amino acid or ketoacid supplementation) is an effective treatment of patients with diabetic nephropathy?-
References
Gannon MC, Nuttall JA, Damberg G, Gupta V, Nuttall FQ. Effect of protein ingestion on the glucose appearance rate in people with type 2 diabetes. J Clin Endocrin Metab. 2001;86:1040-1047.
Gannon MC, Nuttall FQ, Saeed A, Jordan K, Hoover H. An increase in dietary protein improves the blood glucose response in persons with type 2 diabetes. Am J Clin Nutr. 2003;78:734-741.
Luscombe ND, Clifton PM, Noakes M, Parker B, Wittert G. Effects of energy-restricted diets containing increased protein on weight loss, resting energy expenditure, and the thermic effect of feeding in type 2 diabetes. Diabetes Care 2002;25:652-657
Nordt TK, Besenthal I, Eggstein M, Jakober B. Influence of breakfasts with different nutrient contents on glucose, C peptide, insulin, glucagon, triglycerides, and GIP in non-insulin-dependent diabetics. Am J Clin Nutr. 1991;53:155-160.
Nuttall FQ, Gannon MC, Saeed A, Jordan K, Hoover H. The metabolic response of subjects with type 2 diabetes to a high-protein, weight-maintenance diet. J Clin Endocrinol Metab. 2003;88:3577-3583.
Parker B, Noakes M, Luscombe N, Clifton P. Effect of a high-protein, high-monounsaturated fat weight loss diet on glycemic control and lipid levels in type 2 diabetes. Diabetes Care 2002;25:425-430.
Azadbakht L, Shakerhosseini R, Atabak S, Jamshidian M, Mehrabi Y, Esmaill-Zadeh A. Beneficiary effect of dietary soy protein on lowering plasma levels of lipid and improving kidney function in type II diabetes with nephropathy. Eur J Clin Nutr 2003;57:1292-1294.
Hansen HP, Christensen PK, Tauber-Lassen E, Klausen A, Jensen BR, Parving H. Low-protein diet and kidney function in insulin-dependent diabetic patients with diabetic nephropathy. Kidney International. 1999;55:621-628.
Hansen HP, Tauber-Lassen E, Jensen BR, Parving H-H. Effect of dietary protein restriction on prognosis in patients with diabetic nephropathy. Kidney Int 2002:61:220-228.
Meloni C, Morosetti M, Suraci C, Pennafina MG, Tozzo C, Taccone-Gallucci M, Casciani CU. Severe dietary protein restriction in overt diabetic nephropathy: Benefits or risks? J Renal Nutr 2002;12:96-101.
Meloni C, Tatangelo P, Cipriani S, Rossi V, Suraci C, Tozzo C, Rossini B, Cecilia A, DiFranco D, Straccialano E, Casciani CU. Adequate protein dietary restriction in diabetic and nondiabetic patients with chronic renal failure. Journal of Renal Nutrition 2004; 14 (4): 208-213.
Pijls LTJ, de Vries H, van Eijk JThM, Donker AJM. Protein restriction, glomerular filtration rate and albuminuria in patients with type 2 diabetes mellitus: a randomized trial. Eur J Clin Nutr. 2002;56:1200-1207.
Pijls LTJ, de Vries H, Kriegsman DMW, Donker AJM, van Eijk JThM. Determinants of albuminuria in people with Type 2 diabetes mellitus. Diabetes Res Clin Pract. 2001:52:133-143.
Raal FJ, Kalk WJ, Lawson M, Esser JD, Buys R, Fourie L, Panz VR. Effect of moderate dietary protein restriction on the progression of overt diabetic nephropathy: a 6-month prospective study. Am J Clin Nutr. 1994;60:579-585.
Stojceva-Taneva O, Polenakovic M, Grozdanovski R, Sikole A. Lipids, protein intake and progression of diabetic nephropathy. Nephrol Dial Transplant. 2001; 16[suppl 1]: 90-91. -
References not graded in Academy of Nutrition and Dietetics Evidence Analysis Process
American Diabetes Association. Nutrition recommendations and interventions for diabetes: a position statement of the American Diabetes Association. Diabetes Care 2007;30 Suppl 1:S48-65.
Wylie-Rosett J, Albright AA, Apovian C, Clark NG, Delahanty L, Franz MJ, Hoogwerf B, Kulkarni K, Lichtenstein AH, Mayer-Davis E, Mooradian AD, Wheeler M. 2006-2007 American Diabetes Association Nutrition Recommendations: issues for practice translation. J Am Diet Assoc 2007;107(8):1296-304.
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References