Recommendations Summary
DM: Fiber 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: Fiber Intake and Glycemia
Recommendations for fiber intake for people with diabetes are similar to the recommendations for the general public (DRI: 14 grams per 1000 kcal). While diets containing 44 to 50 grams of fiber daily are reported to improve glycemia; more usual fiber intakes (up to 24 grams daily) have not shown beneficial effects on glycemia. It is unknown if free-living individuals can daily consume the amount of fiber needed to improve glycemia.
Rating: Strong
ImperativeDM: Fiber Intake and Cholesterol
Include foods containing 25-30 grams of fiber per day, with special emphasis on soluble fiber sources (7-13 grams). Diets high in total and soluble fiber, as part of cardioprotective nutrition therapy, can further reduce total cholesterol by 2-3% and LDL cholesterol up to 7%.
Rating: Strong
Imperative-
Risks/Harms of Implementing This Recommendation
- Excessive fiber intake can potentially have undesirable gastrointestinal side effects.
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Conditions of Application
None.
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Potential Costs Associated with Application
- Although costs of MNT sessions and reimbursement vary, medical nutrition therapy sessions are essential for improved outcomes.
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Recommendation Narrative
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There is inconclusive evidence that increasing dietary fiber will influence glycemic outcome in people with diabetes.
- Two studies with higher fiber and lower fiber diets both containing similar macronutrient percents of energy (Hagander et al, 1998; Chandalia et al, 2000) showed no significant difference between diets for A1C, and one study (Giacco et al, 2000) showed a 2% reduction in A1C only in subjects compliant with the 50 gram fiber diet.
- Three studies (Chandalia et al, 2000; Giacco et al, 2000; Kinmonth et al, 1982) found 24-hr glycemic profiles significantly lower on the higher fiber diet vs the lower fiber diet and one study (Del Toma et al, 1998) showed significantly lower postprandial glucose levels on the higher fiber vs the lower fiber diet.
- Two studies with higher fiber and lower fiber diets having different macronutrient percents of energy (Anderson et al, 1991; Milne et al, 1994) showed no change in A1C between diets; however, two studies (McCulloch et al, 1985; Stevens et al, 1985) showed significant improvement in A1C with the higher fiber diet vs the lower fiber diet.
- Three studies (Lindsay et al, 1984; Riccardi et al, 1984; Story et al, 1985) found no change in fasting blood glucose between diets, and one study (Simpson et al, 1988) found significant improvement in FBG for the higher fiber vs the lower fiber diet.
- One cross-sectional study (Buyken et al, 1998) found that fiber intake was inversely related to A1C and the other (Shimakawa et al, 1993) showed no relationship.
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When the above studies are divided according to environment (controlled or free living), type of diabetes, or “good” or “poor” control, they showed the same results.
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There appears to be conclusive evidence that higher fiber diets will lower total cholesterol significantly vs lower fiber diets. In eight studies lipids were a measured outcome. Seven studies (Riccardi et al, 1984; Stevens et al, 1985; Story et al, 1985; Hagander et al, 1988; Simpson et al, 1988; Anderson et al, 1991; Chandalia et al, 2000) showed a significant decrease in total cholesterol in the higher fiber group compared to the lower fiber group and one (Milne et al, 1994) showed no change. Three of the eight studies reported significantly reduced HDL-cholesterol (Riccardi et al, 1984; Simpson et al, 1988; Anderson et al, 1991).
- Consuming diets high in total dietary fiber (greater than 25 grams per day) is associated with decreased risk for CHD and CVD (Van Horn, 1997; Liu et al, 1999; Wolk et al, 1999; Liu et al, 2002; Bazzano et al, 2003; Merchant et al, 2003; Pereira et al, 2004).
- Consuming diets high in total fiber (17-30 g/day) and soluble fiber (7-13 g/day) as part of a diet low in saturated fat and cholesterol can further reduce total cholesterol by 2-3% and LDL up to 7% (Brown et al, 1999; Ludwig et al, 1999; Saltzman et al, 2001; Van Horn et al, 2001; Davy et al, 2002; Jenkins et al, 2002).
- Limited research indicates that other risk factors for CHD may be modified by a diet low in saturated fat and cholesterol and high in total and soluble fiber. These risk factors include blood pressure, lipoprotein subclasses and particle sizes, and fasting and post-prandial insulin (Brown et al, 1999; Ludwig et al, 1999; Saltzman et al, 2001; Van Horn et al, 2001; Davy et al, 2002; Jenkins et al, 2002).
- American Diabetes Association Recommendation: As for the general population, people with diabetes are encouraged to consume a variety of fiber-containing foods. However, evidence is lacking to recommend a higher fiber intake for people with diabetes than for the population as a whole (Grade B).
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Recommendation Strength Rationale
- Conclusion Statement for Fiber and Diabetes given Grade I
- Conclusion Statements for Fiber and CHD given Grades I, II and III
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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 fiber and metabolic outcomes in persons with type 1 and type 2 diabetes?
What does the evidence indicate is the relationship between fiber intake and Coronary Heart Disease outcomes?
Will consuming high fiber foods as part of a diet low in saturated fat and cholesterol reduce total cholesterol and LDL even more than a diet low in saturated fat and cholesterol alone?
What risk factors for CHD may be modified by a diet low in saturated fat and cholesterol and high in total and soluble fiber?-
References
Anderson JW, Zeigler JA, Deakins DA, Floore TL, Dillon DW, Wood CL, Oeltgen PR, Whitley RJ. Metabolic effects of high-carbohydrate, high-fiber diets for insulin-dependent diabetic individuals. Am J Clin Nutr 1991;54:936-943.
Buyken AE, Toeller M, Heitkamp G, Vitelli F, Stehle P, Scherbaum WA, Fuller JH and the EURODIAB IDDM Complications Study Group. Relation of fibre intake to HbA1c and the prevalence of severe ketoacidosis and severe hypoglycaemia. Diabetologia 1998;41:882-890.
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. 2000:342:1392-1398.
Del Toma E, Lintas C, Clementi A, Marcelli M. Soluble and insoluble dietary fiber in diabetic diets. Eur J Clin Nutr. 1988;42: 313-319.
Giacco R, Parillo M, Rivellese AA, Lasorella G, Giacco A, D'Episcopo L, Riccardi G. Long-term dietary treatment with increased amounts of fiber-rich low-glycemic index natural foods improves blood glucose control and reduces the number of hypoglycemic events in type 1 diabetic patients. Diabetes Care. 2000;23:1461-1466.
Hagander B, Asp N-G; Efendic S, Nilsson-Ehle P, Schersten B. Dietary fiber decreases fasting blood glucose levels and plasma LDL concentration in noninsulin-dependent diabetes mellitus patients. Am J Clin Nutr 1988;47(5):852-858.
Kinmonth A-L, Angus RM, Jenkins PA, Smith MA, Baum JD. Whole foods and increased dietary fibre improve blood glucose control in diabetic children. Arch Dis Childhood. 1982;57:187-194.
Lindsay AN, Hardy S, Jarrett L, Rallison ML. High-carbohydrate, high-fiber diet in children with type 1 diabetes mellitus. Diabetes Care 1984;7(1):63-67.
McCulloch DK, Mitchell RD, Ambler J, Tattersall RB. A prospective comparison of "conventional" and high carbohydrate/high fibre/low fat diets in adults with established type 1 (insulin-dependent) diabetes. Diabetologia 1985;28:208-212.
Milne RM, Mann JI, Chisholm AW, Williams SM. Long-term comparison of three dietary prescriptions in the treatment of NIDDM. Diabetes Care 1994;17:74-80.
Riccardi G, Rivellese A, Pacioni D, Genovese S, Mastranzo P, Mancini M. Separate influence of dietary carbohydrate and fibre on the metabolic control in diabetes. Diabetologia. 1984;26:116-121.
Shimakawa T, Warram JH, Herrera-Acena MG, Krolewski AS. Usual dietary intake and hemoglobin A1 level in patients with insulin-dependent diabetes. J Am Diet Assoc 1993;93:1409-1412, 1415.
Simpson RW, McDonald J, Wahlqvist ML, Balasz N, Sissons M, Atley L. Temporal study of metabolic change when poorly controlled noninsulin-dependent diabetics change from low to high carbohydrate and fiber diet. Am J Clin Nutr 1988;48:104-109.
Stevens J, Burgess MB, Kaiser DL, Sheppa CM. Outpatient management of diabetes mellitus with patient education to increase dietary carbohydrate and fiber. Diabetes Care. 1985;8:359-366.
Story L, Anderson JW, Chen W-JL, Karounos D, Jefferson B. Adherence to high-carbohydrate, high-fiber diets: long-term studies of non-obese diabetic men. J Am Diet Assoc. 1985; 85:1105-1110.
Bazzano, L.A., He, J., Ogden, L.G., Loria, C.M., Whelton, P.K. Dietary fiber intake and reduced risk of coronary heart disease in us men and women. Arch Intern Med. 2003; 163:1897-1904.
Liu S, Stampfer MJ, Hu FB, Giovannucci E, Rimm E, Manson JE, Hennekens CH, Willett WC. Whole-grain consumption and risk of coronary heart disease: Results from the Nurses’ Health Study. Am J Clin Nutr. 1999; 70: 412-419.
Liu, S., Buring, J., Sesso, H., Rimm, E., Willett, W., Manson, J. A prospective study of dietary fiber intake and risk of cardiovascular disease among women. J Am Coll Cardiol 2002,39:49-56
Merchant AT, Hu FB, Spieglman D, Willett WC, Rimm EB, Ascherio A. Dietary fiber reduces peripheral arterial disease risk in men. J Nutr. 2003;133: 3658-3663.
Pereira MA, O'Reilly E, Augustsson K, Fraser GE, Goldbourt U, Heitmann BL, Hallmans G, Knekt P, Liu S, Pietinen P, Spiegelman D, Stevens J, Virtamo J, Willett WC, Ascherio A.. Dietary fiber and risk of coronary heart disease. Arch Intern Med. 2004; 164: 370-376.
Van Horn L. Fiber, lipids, and coronary heart disease. A statement for healthcare professionals from the Nutrition Committee, American Heart Association. Circulation. 1997;95:2701-2704.
Wolk J, Mason JE, Stampfer MJ, et al. Long-term intake of dietary fiber and decreased risk of coronary heart disease among women. JAMA. 1999;281:1998-2004.
Brown L, Rosner B, Willett WW, Sacks FM. Cholesterol-lowering effects of dietary fiber: a meta-analysis. Am J of Clin Nutr. 1999;69:30-42
Davy BM, Davy KP, Ho RC, Beske SD, Davrath LR, Melby CL. High-fiber oat cereal compared with wheat cereal consumption favorable alters LDL-cholesterol subclass and particle numbers in middle-aged and older men. Am J Clin Nutr . 2002; 76:351-358.
Jenkins, D., Kendall, C., Vuksan, V., Vidgen, E., Parker, T., Faulkner, D., Mehling, C., Garsetti, M., Testolin, G., Cunnane, S., Ryan M., Corey, P. Soluble fiber intake at a dose approved by the us food and drug administration for a claim of health benefits: serum lipid risk factors for cardiovascular disease assessed in a randomized controlled crossover trial. Am J Clin Nutr. 2002;75:834-9.
Ludwig DS, Pereira MA, Kroenke CH, Hilner JE, Van Horn L, Slattery ML, Jacobs DR Jr. Dietary fiber, weight gain, and cardiovascular disease risk factors in young adults. JAMA 1999;99:1539-1546.
Saltzman E, Das SK, Lichtenstein AC, Dallal GE, Corrales A, Schaefer EJ, Greenberg AS, Roberts SB. An oat-containing hypocaloric diet reduces systolic blood pressure and improves lipid profile beyond effects of weight loss in men and women. J Nutr. 2001;131:1465-1470.
Van Horn L, Liu K, Gerber J, Garside D, Schiffer L, Gernhofer N, Greenland P. Oats and soy in lipid-lowering diets for women with hypercholesterolemia: is there synergy? J Am Diet Assoc. 2001; 101:1319-1325. -
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.
Institute of Medicine: Dietary Reference Intakes: Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids. Washington, DC, National Academies Press, 2002.
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