Nutrition Intervention
DM: Individualize Nutrition Prescription
The registered dietitian nutritionist (RDN) should individualize the nutrition prescription and implement evidence-based guidelines in collaboration with the adult with diabetes. A variety of eating patterns (combinations of different foods or food groups) are acceptable for the management of diabetes. Personal preferences (e.g., tradition, culture, religion, health beliefs and goals, economics) and metabolic goals should be considered when recommending one eating pattern over another. Treatment decisions should be founded on evidence-based guidelines tailored to individual patient preferences, prognoses and co-morbidities.
DM: Encourage Healthful Eating Plan for Appropriate-Weight Adults with Diabetes
For appropriate-weight adults with diabetes, the registered dietitian nutritionist (RDN) should encourage consumption of a healthful eating plan, with a goal of weight maintenance and prevention of weight gain. A variety of eating patterns (combinations of different foods or food groups) are acceptable for the management of diabetes.
DM: Encourage Reduced Energy Healthful Eating Plan for Overweight or Obese Adults with Diabetes
For overweight or obese adults with diabetes, the RDN should encourage a reduced energy, healthful eating plan, with a goal of weight loss, weight loss maintenance and prevention of weight gain. Studies based on reduced energy interventions reported significant reductions in HbA1c of 0.3% to 2.0% in adults with type 2 diabetes and of 1.0% to 1.9% in adults with type 1 diabetes, as well as optimization of medication therapy and improved quality of life.
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.
Diabetes (DM) Type 1 and 2: Carbohydrate Management Strategies
The registered dietitian nutritionist (RDN) should educate adults with type 1 diabetes or type 2 diabetes on multiple daily injections (MDI) of insulin or insulin pump therapy on carbohydrate counting using insulin-to-carbohydrate ratios based on his or her abilities, preferences and management goals. Research reports that carbohydrate counting using insulin-to-carbohydrate ratios resulted in significant decreases in A1C of 0.4% to 1.6% and significant increases in quality of life, as well as continued maintenance of these improvements for up to 44 months. The majority of research reported no significant change in weight as a result of this carbohydrate management strategy.
DM: Educate Adults with Type 1 or Type 2 Diabetes on Fixed Insulin Doses or Adults with Type 2 Diabetes on Insulin Secretagogues
The registered dietitian nutritionist (RDN) should educate adults with type 1 diabetes or type 2 diabetes on fixed insulin doses or adults with type 2 diabetes on insulin secretagogues, based on his or her abilities, preferences and management goals, on carbohydrate consistency (timing and amount) using one of the following carbohydrate management strategies:
- Carbohydrate counting alone
- Plate method, portion control and simplified meal plan
- Food lists (such as Choose Your Foods. Food Lists for Diabetes) and carbohydrate choices.
For individuals using fixed insulin doses (or insulin secretagogues), consistent carbohydrate intake with respect to time and amount can result in improved glycemic control and reduce risk for hypoglycemia. Monitoring carbohydrate intake, whether by carbohydrate counting or experience-based estimation remains a key strategy in achieving glycemic control. A simple diabetes healthful eating plan approach such as portion control or healthful food choices may be better suited to individuals with type 2 diabetes who have low health literacy or numeracy concerns.
DM: Educate Adults with Type 2 Diabetes on MNT Alone or Non-Insulin Secretagogues
The registered dietitian nutritionist (RDN) should educate adults with type 2 diabetes on medical nutrition therapy (
MNT) alone or on diabetes medications other than insulin secretagogues, based on his or her abilities, preferences and management goals, on one of the following carbohydrate management strategies:
- Carbohydrate counting alone
- Plate method, portion control and simplified meal plan
- Food lists (such as Choose Your Foods. Food Lists for Diabetes) and carbohydrate choices.
Monitoring carbohydrate intake, whether by carbohydrate counting or experience-based estimation remains a key strategy in achieving glycemic control. A simple diabetes healthful eating plan approach such as portion control or healthful food choices may be better suited to individuals with type 2 diabetes who have low health literacy or numeracy concerns.
DM: Encourage Fiber Intake
The registered dietitian nutritionist (RDN) should encourage adults with diabetes to consume dietary fiber from foods such as fruits, vegetables, whole grains and legumes, at the levels recommended by the Dietary Reference Intakes (DRI) (21g to 25g per day for adult women and 30g to 38g per day for adult men, depending on age) or U.S. Department of Agriculture (14g fiber per 1,000kcal) due to the overall health benefits of dietary fiber. Limited research regarding differing amounts of fiber intake from foods, independent of weight loss, reported mixed results on A1C and no significant effects on exogenous insulin levels.
DM: Advise on Glycemic Index and Glycemic Load
If glycemic index or glycemic load is proposed as a glycemia-lowering strategy, the registered dietitian nutritionist (RDN) can advise adults with diabetes that lowering glycemic index or glycemic load may or may not have a significant effect on glycemic control. Studies longer than 12 weeks report no significant impact of glycemic index or glycemic load, independent of weight loss, on A1C. However, mixed results were reported regarding fasting glucose levels and endogenous insulin levels.
DM: Educate on Substitution of Nutritive Sweeteners for Other Carbohydrates
The registered dietitian nutritionist (RDN) should educate adults with diabetes that intake of nutritive sweeteners, when substituted isocalorically for other carbohydrates, will not have a significant effect on A1C or insulin levels. Research reported no significant impact of consuming nutritive sweeteners (such as isomaltulose and sucrose), independent of weight loss, on A1C or insulin levels. However, mixed results were reported regarding fasting blood glucose.
DM: Advise Against Excessive Intake of Nutritive Sweeteners
The registered dietitian nutritionist (RDN) should advise adults with diabetes against excessive intake of nutritive sweeteners to avoid displacing nutrient-dense foods and to avoid excessive caloric and carbohydrate intake. Higher intake of added sugars may contribute to higher energy intake.
DM: Educate on Intake of FDA-approved Non-nutritive Sweeteners
The registered dietitian nutritionist (RDN) should educate adults with diabetes that intake of FDA-approved non-nutritive sweeteners (such as aspartame, sucralose and stevia) within the recommended daily intake levels established by FDA will not have a significant effect on glycemic control. Research reports no significant impact of consuming FDA-approved non-nutritive sweeteners [such as aspartame, stevia (steviol glycosides) and sucralose], independent of weight loss, on A1C, fasting glucose levels or insulin levels.
DM: Educate About Substitution of FDA-Approved Non-Nutritive Sweeteners
The registered dietitian nutritionist (RDN) should educate adults with diabetes that substituting foods and beverages containing FDA-approved non-nutritive sweeteners within the recommended daily intake levels established by FDA can reduce overall calorie and carbohydrate intake. However, other sources of calories and carbohydrates in these foods and beverages need to be considered. Use of non-nutritive sweeteners has the potential to reduce overall calorie and carbohydrate intake if substituted for caloric sweeteners without compensation by intake of additional calories from other food sources.
DM: Educate on Protein Intake and Hypoglycemia in Adults with Diabetes
The registered dietitian nutritionist (RDN) should educate adults with diabetes that adding protein to meals and snacks does not prevent or assist in the treatment of hypoglycemia. Ingested protein appears to increase insulin response without increasing plasma glucose concentrations; therefore, carbohydrate sources high in protein should not be used to treat or prevent hypoglycemia.
DM: No Protein Restriction for Diabetic Kidney Disease (DKD)
For adults with diabetes and diabetic kidney disease (DKD), the registered dietitian nutritionist (RDN) does not need to prescribe a protein restriction. While research reports mixed results regarding the effects of the amount of protein on fasting glucose levels and A1C, independent of weight loss, in adults with type 1 diabetes and type 2 diabetes and DKD, there was no significant impact of protein intake (ranging from 0.7g to 2.0g per kg per day) on GFR.
DM: Type of Protein and Diabetic Kidney Disease (DKD)
The registered dietitian nutritionist (RDN) should advise adults with type 2 diabetes and diabetic kidney disease (DKD) that the type of protein (vegetable-based vs.animal-based) will not have a significant effect on GFR. However, there may be an effect on fasting glucose levels and proteinuria. While one study reports a positive impact of soy protein compared to animal protein on proteinuria and fasting glucose levels, independent of weight loss, in adults with type 2 diabetes and DKD, there was no significant impact of soy protein consumption on GFR.
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.
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.
DM: Advise on Vitamin, Mineral and Herbal Supplementation
If vitamin, mineral and herbal supplementation is proposed as a diabetes management strategy, the registered dietitian nutritionist (RDN) can advise adults with diabetes that there is no clear evidence of benefit from supplementation in people who do not have underlying deficiencies. Routine supplementation with antioxidants (such as vitamins E and C and carotene) and other micronutrients (such as chromium, magnesium and vitamin D) and herbal supplements (such as cinnamon) are not advised due to lack of evidence of efficacy and concern related to long-term safety.
DM: Advise and Educate on Alcohol Consumption
The registered dietitian nutritionist (RDN) should advise and educate adults with diabetes that if they choose to drink alcohol, they should do so in moderation (one drink per day or less for adult women and two drinks per day or less for adult men). Alcohol consumption may place adults with diabetes at increased risk for delayed hypoglycemia, especially if using insulin or insulin secretagogues.
DM: Encourage Individualized Physical Activity Plan
The registered dietitian nutritionist (
RDN) should encourage an individualized
physical activity plan for
adults with diabetes, unless medically contraindicated, to gradually achieve the following:
- Accumulating 150 minutes or more of physical activity per week
- Moderate-intensity aerobic exercise (50% to 70% of maximum heart rate) spread over at least three days per week with no more than two consecutive days without exercise
- Resistance training at least twice per week
- Reduce sedentary time by breaking up extended amounts of time (more than 90 minutes) spent sitting.
Adults with diabetes should be advised to perform at least 150 minutes per week of moderate-intensity aerobic physical activity (50% to 70% of maximum heart rate), spread over at least three days per week with no more than two consecutive days without exercise.
DM: Educate on Prevention and Treatment of Exercise-Related Hypoglycemia
The registered dietitian nutritionist (RDN) should educate adults with diabetes taking insulin or insulin secretagogues that physical activity may cause hypoglycemia if medication doses or carbohydrate consumption is not altered. Individual glycemic response patterns can differ markedly with exercise; therefore, persons with diabetes taking insulin or insulin secretagogues must use glucose monitoring and recognition of glucose patterns to make decisions to exercise safely.
DM: Education on Glucose Monitoring
The registered dietitian nutritionist (RDN) should ensure that adults with type 1 diabetes and type 2 diabetes are educated about glucose monitoring and using data to adjust therapy. When prescribed as part of a broader educational context, results may help guide treatment decisions and self-management.
DM: Coordination of Care
The registered dietitian nutritionist (RDN) should implement medical nutrition therapy (MNT) and coordinate care with an interdisciplinary health care team, the adult with diabetes and important others (e.g., family, friends and colleagues). Care systems should support team-based care and community involvement to meet patient needs, ensuring productive interactions between a prepared, proactive practice team and an informed, activated patient.