Quick Links

  • Increase Font Size
  • Decrease Font Size
  • View as PDF

Recommendations Summary

DM: Macronutrient Composition (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: Individualize Macronutrient Composition

    The registered dietitian nutritionist (RDN), in collaboration with the adult with diabetes, should individualize the macronutrient composition of the healthful eating plan within the appropriate energy intake. Limited research regarding differing amounts of carbohydrate (39% to 57% of energy) and fat (27% to 40% of energy), reported no significant effects on A1C or insulin levels in adults with diabetes, independent of weight loss. Limited research reports mixed results regarding the effects of the amount of protein (ranging from 0.8g to 2.0g per kg per day) on fasting glucose levels and A1C.

     

    Rating: Fair
    Imperative

    • Risks/Harms of Implementing This Recommendation

      None.

    • Conditions of Application

      When individualizing the macronutrient composition, the RDN may consider the following:

      • Lifestyle
      • Physical activity level
      • Personal preferences
      • Current eating pattern or plan
      • Willingness to comply
      • Culture
      • Religion
      • Economics
      • Literacy
      • Accessibility.
      In individuals with type 1 diabetes, higher-fat meals may cause prolonged post-prandial glucose excursions, which may require changes in insulin regimen such as dual-wave bolus delivery or splitting of mealtime insulin dose. 

    • Potential Costs Associated with Application

      Costs of MNT sessions and reimbursement vary; however, MNT sessions are essential for improved outcomes.

    • Recommendation Narrative

      • Research reports mixed results regarding the effects of the amount of protein (ranging from 0.8g to 2.0g per kg per day) on fasting glucose levels and A1C, independent of weight loss, in adults with type 1 diabetes and type 2 diabetes and diabetic kidney disease (DKD) (Raal et al, 1994; Hansen et al, 2002; Velazquez et al, 2008). Grade III
      • Research reports that the amount of protein (ranging from 0.7g to 2.0g per kg per day) had no effect on glomerular filtration rate (GFR), independent of weight loss, in adults with type 1 diabetes and type 2 diabetes and diabetic kidney disease (DKD). No studies reported on proteinuria (Robertson et al, 2007; Velazquez et al, 2008). Grade I
      • There were no studies identified regarding the relationship of differing amounts of protein, independent of weight loss, on insulin levels (exogenous or endogenous) in adults with type 1 diabetes and type 2 diabetes. Intervention studies are needed regarding the impact of differing amounts of protein on insulin levels in adults with diabetes. Grade V
      • Three studies regarding the relationship of differing amounts of carbohydrate (39% to 57% of energy), independent of weight loss, reported no significant effect on A1C in adults with type 1 diabetes and type 2 diabetes (Wolever et al, 2008; Delahanty et al, 2009; Strychar et al, 2009). One study in adults with type 2 diabetes reported a significantly higher fasting glucose and lower two-hour post-load glucose in subjects following a higher-carbohydrate, lower-glycemic index and lower-fat diet (Wolever et al, 2008). Additional long-term studies are needed regarding the relationship of differing amounts of carbohydrate on glycemia in adults with diabetes. Grade III
      • Two studies regarding the relationship of differing amounts of carbohydrate (39% to 57% of energy), independent of weight loss, reported no significant effect on exogenous insulin doses in adults with well-controlled type 1 diabetes (Strychar et al, 2009) and no significant effect on endogenous insulin levels in adults with well-controlled type 2 diabetes (Wolever et al, 2008). Additional long-term studies are needed regarding the relationship of differing amounts of carbohydrate on insulin levels in adults with diabetes. Grade III
      • Two studies, one in adults with well-controlled type 1 diabetes and another in adults with well-controlled type 2 diabetes, regarding the relationship of differing amounts of carbohydrate (39% to 57% of energy), independent of weight loss, on CVD risk factors reported no significant effect on total cholesterol, LDL-cholesterol or blood pressure levels (Wolever et al, 2008; Strychar et al, 2009). Research regarding differing amounts of carbohydrate reports no significant effect on HDL-cholesterol and triglyceride levels in adults with type 1 diabetes (Strychar et al, 2009), while decreased HDL-cholesterol and increased triglyceride levels were reported when consuming a higher-carbohydrate, lower-glycemic index and lower-fat diet in adults with type 2 diabetes (Wolever et al, 2008). 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 amounts of carbohydrate, independent of weight loss, on lipid profile in adults with diabetes, especially those with disorders of lipid metabolism and hypertension. Grade III
      • Three studies regarding the relationship of differing amounts of fat (27% to 40% of energy), independent of weight loss, reported no significant effect on A1C in adults with type 1 diabetes and type 2 diabetes (Wolever et al, 2008; Delahanty et al, 2009; Strychar et al, 2009). One study in adults with type 2 diabetes reported a significantly higher fasting glucose and lower two-hour post-load glucose in subjects following a higher carbohydrate, lower-glycemic index and lower-fat diet (Wolever et al, 2008). Additional long-term studies are needed regarding the relationship of differing amounts of fat on glycemia in adults with diabetes. Grade III
      • Two studies regarding the relationship of differing amounts of fat (27% to 40% of energy), independent of weight loss, reported no significant effect on exogenous insulin doses in adults with well-controlled type 1 diabetes (Strychar et al, 2009) and no significant effect on endogenous insulin levels in adults with well-controlled type 2 diabetes (Wolever et al, 2008). Additional long-term studies are needed regarding the relationship of differing amounts of fat on insulin levels in adults with diabetes. Grade III
      • Two studies, one in adults with well-controlled type 1 diabetes (Strychar et al, 2009) and another in adults with well-controlled type 2 diabetes (Wolever et al, 2008), regarding the relationship of differing amounts of fat (27% to 40% of energy), independent of weight loss, on CVD risk factors reported no significant effect on total cholesterol, LDL-cholesterol or blood pressure levels. Research regarding differing amounts of fat reports no significant effect on HDL-cholesterol and triglyceride levels in adults with type 1 diabetes (Strychar et al, 2009), while decreased HDL-cholesterol and increased triglyceride levels were reported when consuming a higher-carbohydrate, lower-glycemic index and lower-fat diet in adults with type 2 diabetes (Wolever et al, 2008). 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 amounts of fat, independent of weight loss, on lipid profile in adults with diabetes, especially those with disorders of lipid metabolism and hypertension. Grade III

      From the 2013 American Diabetes Association Nutrition Therapy Recommendations

      • Evidence suggests that there is not an ideal percentage of calories from carbohydrate, protein and fat for all people with diabetes (Grade B); therefore, macronutrient distribution should be based on individualized assessment of current eating patterns, preferences and metabolic goals. (Grade E)
      • Evidence is inconclusive for an ideal amount of carbohydrate intake for people with diabetes. Therefore, collaborative goals should be developed with the individual with diabetes. Grade C
      • 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)

      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 suggests that there is not an ideal percentage of calories from carbohydrate, protein and fat for all people with diabetes (Grade B); therefore, macronutrient distribution should be based on individualized assessment of current eating patterns, preferences and metabolic goals. Grade E

    • Recommendation Strength Rationale

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

    • Minority Opinions

      Consensus reached.