Diabetes and Protein

Citation:
 
Study Design:
Class:
- Click here for explanation of classification scheme.
Quality Rating:
Research Purpose:

The 2002 Position Statement: Evidence-Based Nutrition Principles and Recommendations for the Treatment and Prevention of Diabetes and Related Complications, provides principles and recommendations classified according to the level of evidence available using the American Diabetes Association (ADA) evidence grading system.

The goal of evidence-based recommendations is to improve diabetes care by increasing the awareness of clinicians and persons with diabetes about beneficial nutrition therapies.

Inclusion Criteria:
Not mentioned.
Exclusion Criteria:
Not mentioned.
Description of Study Protocol:

Recruitment: not applicable

Study Design:  not applicable

Intervention:  not applicable

Blinding Used:  not applicable

Statistical Analysis:  not applicable

Data Collection Summary:

Timing of Measurements: not applicable

Dependent Variables:  not applicable

Independent Variables:  not applicable

Control Variables:  not applicable

Description of Actual Data Sample:

Initial N:  not applicable

Attrition (final N):  not applicable

Age: not applicable

Ethnicity:  not applicable

Other relevant demographics:  not applicable

Anthropometrics:  not applicable

Location:  not applicable

Summary of Results:

Goals of Medical Nutrition Therapy for Diabetes:

1. Attain and maintain optimal metabolic outcomes including:

a. blood glucose as close the normal range as possible to prevent or decrease the risk for complications of diabetes.

b. a lipid and lipoprotein profile that decrease the risk of macrovascular disease.

c. blood pressure levels that decrease the risk for vascular disease.

2. Prevent and treat chronic complications of diabetes. Modify nutrient intake and lifestyle for prevention and treatment of obesity, dyslipidemia, cardiovascular disease, hypertension, and nephropathy.

3. Improve health through healthy food choices and physical activity.

4. Address individual nutritional needs taking into consideration personal, ethnic and cultural preferences and lifestyle while respecting the individual’s wishes and willingness to change.

Goals of MNT in Specific Situations:

1. Youth, type 1: Provide adequate energy to ensure normal growth and development, integrate insulin regimens into usual eating and physical activity habits.

2. Youth, type 2: Facilitate changes in eating and physical activity habits that decrease insulin resistance and improve metabolic status.

3. Pregnancy and lactation: Provide adequate energy and nutrients needed for optimal outcomes.

4. Older adults: Provide for the nutritional and psychological needs of an aging individual.

5. Treated with insulin or insulin secretagogues: Provide self-management education for treatment (and prevention) of hypoglycemia, acute illness and exercise-related blood glucose problems.

6. Those at risk for type 2 diabetes: decrease risk by encouraging physical activity and promoting food choices that facilitate moderate weight loss and/or to prevent weight gain.

MNT for Types 1 and 2 Diabetes:

A Level Evidence:

1. Foods containing carbohydrates from whole grains, fruits, vegetables and low fat milk should be included in a healthy diet.

2. The total amount of carbohydrate is more important than the type.

3. Sucrose needs to be substituted for carbohydrate choices.

4. Nonnutritive sweeteners are safe.

B Level Evidence:

1. Those on intensive insulin therapy should adjust premeal insulin dose on carbohydrate content of the meal.

2. There is lack of sufficient evidence of long-term benefit to recommend reduced GI diets as a primary strategy for meal planning.

3. Consumption of dietary fiber is to be encouraged.

C Level Evidence:

1. Those on fixed daily doses of insulin should try to be consistent with day-to-day carbohydrate intake.

Protein:

B Level Evidence:

1. In those with controlled type 2 diabetes, ingested protein does not increase plasma glucose, although protein stimulates insulin secretion to the same extent as carbohydrate.

2. For those in less than optimal control, protein may be greater than the RDA.

Fat:

1. <10% of energy should come from SF. Those with LDL-cholesterol >=100 gm/dL may benefit from <7% SF.

2. Dietary cholesterol should be <300 mg/d and for those with LDL-cholesterol >=100 gm/dL may benefit from <200 mg/d.

B Level Evidence:

1. To lower LDL-cholesterol, energy derived from SFA can be decreased if weight loss is desirable or replaced with either carbohydrate or MUFA if weight loss is not a goal.

3. Intake of trans fatty acids should be minimized.

4. Low fat diets when maintained long-term, contribute to modest weight loss and improvement in dyslipidemia.

Energy Balance and Obesity:

A Level Evidence:

1. In insulin resistance, reduced energy intake and modest weight loss improves insulin resistance and glycemia in the short-term.

2. Structured programs that emphasize lifestyle changes (education, fat intake <30% energy, regular physical activity, regular participant contact) can produce long-term weight loss on the order of 5% to 7% of starting weight.

3. Exercise and behavior modification are most useful adjuncts to other weight loss strategies. Exercise is helpful in maintenance of weight loss.

4. Weight loss diets used alone are unlikely to produce long-term weight loss. Structured, intensive lifestyle programs are necessary.

Micronutrients:

B Level Evidence:

1. There is no clear evidence of benefit from vitamin or mineral supplementation in people with diabetes.

2. Routine supplementation of the diet with antioxidants is not advised because of uncertainties related to long-term efficacy and safety.

Alcohol:

B Level Evidence:

1. For those choosing to use alcohol, daily intake should be limited to 1 drink/d for women and 2 drinks/d for men (1 drink = 12-oz beer, 5-oz wine, or 1.5 oz, 80 proof spirits).

2. To reduce the risk of hypoglycemia, alcohol should be consumed with food.

Type 1 Diabetes:

1. Integration of an insulin regimen in their lifestyle. For those on intensive insulin therapy, the total carbohydrate content of the meals is the major determinant of requirements. For those on a fixed insulin regimen, consistency of carbohydrate is recommended.

Type 2 Diabetes:

1. MNT should emphasize lifestyle changes resulting in decreased energy intake and increased physical activity, and nutrition therapy to decrease glycemia, dyslipidemia and blood pressure.

MNT for the Treatment/ Prevention of Co-Morbid Conditions Hypertension:

A Level Evidence:

1. In both normotensive and hypertensive individuals, a reduction in sodium intake lowers  blood pressure.

2. A modest amount of weight loss beneficially affects blood pressure.

Dyslipidemia:

B Level Evidence:

1. For those with elevated LDL cholesterol, energy from fatty acids should be limited to <10% SFA and <7% trans fatty acids.

2. For persons with elevated TG, low HDL cholesterol (metabolic syndrome), improved glycemic control, modest weight loss, restriction of SFA and use of MUFA and increased physical activity may be beneficial.

Nephropathy:

C Level Evidence:

1. For those with microalbuminuria, a reduction of dietary protein to 0.8 to 1.0 g/kg/d and in those with overt nephropathy, a decrease to 0.8 g/kg/d may slow the progression of nephropathy.

Prevention of Type 2 Diabetes:

A Level Evidence:

1. Structured programs that emphasize lifestyle changes (education, low fat and energy intake, regular physical activity and regular participant contact can produce long-term weight loss of 5% to 7% and decrease the risk of developing type 2 diabetes.

B Level Evidence:

1. Individuals with family members with type 2 diabetes, should be encouraged to participate in regular physical activity to reduce the risk of developing type 2 diabetes.

Author Conclusion:

MNT for people with diabetes should be individualized, with consideration given to the individual’s usual food and eating habits, metabolic profile, treatment goals and desired outcomes.

Monitoring of metabolic parameters, including glucose, HbA1c, lipids, blood pressure, body weight, and renal function, when appropriate as well as quality of life is essential to assess the need for changes in therapy and ensure successful outcomes.

Ongoing nutrition self-management education and care needs to be available for individuals with diabetes. Additionally, many areas of nutrition and diabetes require additional research.

The criteria used for Evidence-Based Recommendations are as follows:

Strong Evidence (Grade A):

• >=2 well done clinical studies reporting similar outcomes

OR

• Approved by the Food and Drug Administration

Some Evidence (Grade B):

• One well done clinical study

OR

• Multiple studies reporting different outcomes but where the weight of the evidence supports a particular point of view.

Limited Evidence (Grade C):

• Consensus of experts based on limited clinical evidence

No Evidence (Grade D):

• Consensus of experts based on clinical experience without supporting evidence.

Funding Source:
Not-for-profit
0
Foundation associated with industry:
Reviewer Comments:

These recommendations are very thorough and are based on an evaluation of the evidence using the above criteria. This criteria for evaluating the evidence is somewhat different than the criteria used by the American Dietetic Association for evaluating evidence for conclusion tables.

These recommendations are for type 1 and 2 diabetes and preventing type 2 diabetes as well as for all ages and conditions including pregnancy and lactation.

Quality Criteria Checklist: Review Articles
Relevance Questions
  1. Will the answer if true, have a direct bearing on the health of patients? Yes
  2. Is the outcome or topic something that patients/clients/population groups would care about? Yes
  3. Is the problem addressed in the review one that is relevant to dietetics practice? Yes
  4. Will the information, if true, require a change in practice? Yes
 
Validity Questions
  1. Was the question for the review clearly focused and appropriate? No
  2. Was the search strategy used to locate relevant studies comprehensive? Were the databases searched and the search termsused described? ???
  3. Were explicit methods used to select studies to include in the review? Were inclusion/exclusion criteria specified andappropriate? Wereselectionmethods unbiased? ???
  4. Was there an appraisal of the quality and validity of studies included in the review? Were appraisal methodsspecified,appropriate, andreproducible? Yes
  5. Were specific treatments/interventions/exposures described? Were treatments similar enough to be combined? N/A
  6. Was the outcome of interest clearly indicated? Were other potential harms and benefits considered? Yes
  7. Were processes for data abstraction, synthesis, and analysis described? Were they applied consistently acrossstudies and groups? Was thereappropriate use of qualitative and/or quantitative synthesis? Was variation in findings among studies analyzed? Were heterogeneity issued considered? If data from studies were aggregated for meta-analysis, was the procedure described? No
  8. Are the results clearly presented in narrative and/or quantitative terms? If summary statistics are used, are levels ofsignificance and/or confidence intervals included? Yes
  9. Are conclusions supported by results with biases and limitations taken into consideration? Are limitations ofthe review identified anddiscussed? No
  10. Was bias due to the review's funding or sponsorship unlikely? No