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Recommendations Summary

DM: Cardioprotective Eating Pattern (2015)

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.


  • Recommendation(s)

    DM: Encourage Cardioprotective Eating Pattern

    The registered dietitian nutritionist (RDN) should encourage consumption of a cardioprotective dietary pattern, within the recommended energy intake. While research reports no significant effect of differing amounts of saturated fat, unsaturated fat and omega-3 fatty acids on glycemia or insulin levels, independent of weight loss, modifications to decrease saturated fat intake and increase unsaturated fat intake reduced total cholesterol and LDL-cholesterol in three of six studies.

     

    Rating: Strong
    Imperative

    DM: Encourage Individualized Reduction in Sodium Intake

    The registered dietitian nutritionist (RDN) should encourage an individualized reduction in sodium intake. The recommendation for the general population to reduce sodium to less than 2, 300mg per day is also appropriate for adults with diabetes; for adults with both diabetes and hypertension, further reduction in sodium intake should be individualized.

    Rating: Fair
    Imperative

    • Risks/Harms of Implementing This Recommendation

      None.

    • Conditions of Application

      The registered dietitian nutritionist should consider the following issues when encouraging a reduction in sodium intake:

      • Palatability
      • Availability
      • Cost of specialty low-sodium products
      • Difficulty in achieving both low-sodium recommendations and a nutritionally adequate eating pattern.
      The registered dietitian nutritionist may refer to the following Academy of Nutrition and Dietetics Evidence-Based Practice Guidelines:

    • Potential Costs Associated with Application

      Costs of medical nutrition therapy (MNT) sessions and reimbursement vary. However, MNT sessions are essential for improved outcomes.

    • Recommendation Narrative

      • Studies regarding the relationship of differing amounts of saturated fat and unsaturated fatty acids, independent of weight loss, reported no significant effect on A1C or glucose levels in adults with type 1 diabetes and type 2 diabetes (Heine et al, 1989; Dullaart et al, 1992; Tapsell et al, 2004; Wolever et al, 2008; Delahanty et al, 2009; Strychar et al, 2009; Jenkins et al, 2011). Grade I
      • Four studies regarding the relationship of differing amounts of saturated fat and unsaturated fatty acids, independent of weight loss, reported no significant effect on exogenous insulin doses in adults with type 1 diabetes (Dullaart et al, 1992; Strychar et al, 2009) and no significant effect on endogenous insulin levels in adults with type 2 diabetes (Heine et al, 1989; Wolever et al, 2008). Grade I
      • Six studies regarding the relationship of differing amounts of saturated fat and unsaturated fatty acids, independent of weight loss, reported no significant effect on triglyceride levels or blood pressure in adults with diabetes (Heine et al, 1989; Dullaart et al, 1992; Tapsell et al, 2004; Wolever et al, 2008; Strychar et al, 2009; Jenkins et al, 2011). However, research regarding differing amounts of saturated fat and unsaturated fatty acids on HDL-cholesterol reported mixed results. Modifications to decrease saturated fat intake and increase unsaturated fat intake reduced total and LDL-cholesterol in three studies and had no effect on total cholesterol and LDL-cholesterol in three studies. Subjects did not have or were not described as having any disorders of lipid metabolism or hypertension. Additional long-term studies are needed to ascertain the relationship of differing types of fat, independent of weight loss, on lipid profile in adults with diabetes, especially those with disorders of lipid metabolism and hypertension. Grade II
      • Seven out of eight studies regarding effect of omega-3 fatty acid supplementation, independent of weight loss, reported no significant effect on A1C or glucose levels in adults with type 1 diabetes or type 2 diabetes (Connor et al, 1993; Morgan et al, 1995; McManus et al, 1996; Rossing et al, 1996; Goh et al, 1997; Pan et al, 2007; Holman et al, 2009; Wong et al, 2010). Grade I
      • Studies regarding the effect of omega-3 fatty acid supplementation, independent of weight loss, reported no significant effect on endogenous insulin levels in adults with type 2 diabetes (McManus et al, 1996; Goh et al, 1997; Pan et al, 2007). No studies were reported on the effect of omega-3 fatty acid supplementation on exogenous insulin levels. Additional long-term studies are needed to ascertain the effect of omega-3 supplementation, independent of weight loss, on insulin levels in adults with diabetes. Grade II
      • Research regarding the effect of omega-3 fatty acid supplementation, independent of weight loss, reported significant dose-dependent decreases in triglyceride levels, particularly in individuals with hypertriglyceridemia (Connor et al, 1993; Morgan et al, 1995; McManus et al, 1996; Rossing et al, 1996; Goh et al, 1997; Pan et al, 2007; Holman et al, 2009; Wong et al, 2010). However, research regarding omega-3 fatty acid supplementation reported no significant or beneficial effect on total cholesterol, HDL-cholesterol, LDL-cholesterol and blood pressure.  Grade I
      From the 2013 American Diabetes Association Nutrition Therapy Recommendations
      • Evidence is inconclusive for an ideal amount of total fat intake for people with diabetes; therefore, goals should be individualized (Grade C); fat quality appears to be far more important than quantity. (Grade B)
      • In people with type 2 diabetes, a Mediterranean-style eating pattern rich in monounsaturated fatty acids may benefit glycemic control and cardiovascular risk factors and can therefore be recommended as an effective alternative to a lower-fat, higher-carbohydrate eating pattern. Grade B
      • Evidence does not support recommending omega-3 (EPA and DHA) supplements for people with diabetes for the prevention or treatment of cardiovascular events. Grade A
      • As recommended for the general public, an increase in foods containing long-chain omega-3 fatty acids (EPA and DHA) (from fatty fish) and omega-3 linolenic acid is recommended for individuals with diabetes because of their beneficial effects on lipoproteins, prevention of heart disease and associations with positive health outcomes in observational studies. Grade B
      • The recommendation for the general public to eat fish (particularly fatty fish) at least two times (two servings) per week is also appropriate for people with diabetes. Grade B
      • The amount of dietary saturated fat, cholesterol and trans fat recommended for people with diabetes is the same as that recommended for the general population. Grade C
      • Individuals with diabetes and dyslipidemia may be able to modestly reduce total-cholesterol and LDL-cholesterol by consuming 1.6g to 3g per day of plant stanols or sterols typically found in enriched foods. Grade C
      • The recommendation for the general population to reduce sodium to less than 2, 300mg per day is also appropriate for people with diabetes. Grade B
      • For individuals with both diabetes and hypertension, further reduction in sodium intake should be individualized. Grade B

      From the 2015 American Diabetes Association Standards of Medical Care in Diabetes

      Foundations of Care: Education, Nutrition, Physical Activity, Smoking Cessation, Psychosocial Care and Immunization

      • Evidence is inconclusive regarding an ideal amount of total fat for people with diabetes; therefore, goals should be individualized. Grade C
      • Fat quality appears to be far more important than quantity. Grade B
      • A Mediterranean-style eating pattern, rich in monounsaturated fatty acids, may benefit glycemic control and CVD risk factors and can therefore be recommended as an effective alternative to a lower-fat, higher-carbohydrate eating pattern. Grade B
      • Increased consumption of foods containing long-chain omega-3 fatty acids (EPA and DHA), such as fatty fish and omega-3 linolenic acid (ALA) is recommended. Grade B
      • The consumption of fish (particularly fatty fish) at least two times (two servings) per week is recommended. Grade B
      • The amount of dietary saturated fat, cholesterol and trans fat recommended for people with diabetes is the same as that recommended for the general population. Grade C
      • Evidence does not support recommending omega-3 supplements for people with diabetes for the prevention or treatment of cardiovascular events. Grade A
      • The recommendation for the general population to reduce sodium to less than 2, 300mg per day is also appropriate for people with diabetes. Grade B
      • For individuals with both diabetes and hypertension, further reduction in sodium intake should be individualized. Grade B

      Cardiovascular Disease and Risk Management

      • Patients with blood pressure more than 120/80mm Hg should be advised on lifestyle changes to reduce blood pressure. Grade B
      • Patients with confirmed office-based blood pressure higher than 140/90mm Hg should, in addition to lifestyle therapy, have prompt initiation and timely subsequent titration of pharmacological therapy to achieve blood pressure goals. Grade A
      • Lifestyle therapy for elevated blood pressure consists of weight loss, if overweight or obese; a Dietary Approaches to Stop Hypertension (DASH)-style dietary pattern including reducing sodium and increasing potassium intake; moderation of alcohol intake; and increased physical activity. Grade B
      • Lifestyle modification focusing on the reduction of saturated fat, trans fat and cholesterol intake; increase of omega-3 fatty acids, viscous fiber and plant stanols or sterols; weight loss (if indicated); and increased physical activity should be recommended to improve the lipid profile in patients with diabetes. Grade A
      • Intensify lifestyle therapy and optimize glycemic control for patients with elevated triglyceride levels [more than 150mg per dL (1.7mmol per L)] or low HDL-cholesterol [less than 40mg per dL (1.0mmol per L) for men, less than 50mg per dL (1.3mmol per L) for women]. Grade C
      • For patients with fasting triglyceride levels higher than 500mg per dL (5.7mmol per L), evaluate for secondary causes and consider medical therapy to reduce risk of pancreatitis. Grade C
      Older Adults

      Other cardiovascular risk factors should be treated in older adults with consideration of the time frame of benefit and the individual patient. Treatment of hypertension is indicated in virtually all older adults, and lipid-lowering and aspirin therapy may benefit those with life expectancy at least equal to the
      time frame of primary or secondary prevention trials. Grade E

    • Recommendation Strength Rationale

      • EAL Conclusion Statements in support of these recommendations were given Grades I and II
      • The 2013 American Diabetes Association Nutrition Therapy Recommendations received Grades of A, B and C
      • The 2015 American Diabetes Association Standards of Medical Care in Diabetes received Grades A, B, C and E.

    • Minority Opinions

      Consensus reached.