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Diet in diabetes

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A diabetic diet is a diet that is used by people with diabetes mellitus or high blood glucose to minimize symptoms (most notably high blood glucose) and dangerous consequences of the disease.

Recommendations of the fraction of total calories to be obtained from carbohydrate are generally in the range of 20% to 45%,[1] but recommendations can vary as widely as from 16% to 75%.[2].

For overweight and obese people with Type 2 diabetes, any weight-loss diet that the person will adhere to and achieve weight loss on is at least partly effective.[3][4]

The most agreed-upon recommendation is for the diet to be low in sugar and refined carbohydrates, while relatively high in dietary fiber, especially soluble fiber. People with diabetes are also encouraged to eat small frequent meals a day. Likewise, people with diabetes may be encouraged to reduce their intake of carbohydrates that have a high glycemic index (GI), although this is also controversial.[5] (In cases of hypoglycemia, they are advised to have food or drink that can raise blood glucose quickly, such as a sugary sports drink, followed by a long-acting carbohydrate (such as rye bread) to prevent risk of further hypoglycemia.) Others question the usefulness of the glycemic index and recommend high-GI foods like potatoes and rice.[citation needed] It has been claimed that oleic acid has a slight advantage over linoleic acid in reducing plasma glucose.[6]

Diet composition

General

People with type 1 diabetes who use insulin can eat whatever they want, preferably a healthy diet with some carbohydrate content; in the long term it is helpful to eat a consistent amount of carbohydrate to make blood sugar management easier.[7]

Macronutrients

To date there is no consensus that eat a diet consisting of any particular macronutrient composition (i.e.: the ratio of fat, protein, and carbohydrate in the diet) is more beneficial for diabetics.[8][9] However, research on diabetic diets is limited due to the nature of nutritional research. Studies in this space tend to be observational as opposed to interventional, relatively short in duration, and have relatively poor compliance due to the difficulty of controlling the diets of study participants at all hours of the day for extended periods of time.[10][9] Thus, more large scale multi-center trials in the future are required to further define recommendations.[10]

Carbohydrates

Carbohydrates include sugars, starches, and fiber. These foods have the greatest impact on blood sugar levels as once they are consumed they are broken down into sugars that absorbed in the small intestine.

The ADA does not recommend a specific amount of carbohydrate consumption for diabetic diets.[8] Although it is not recommended to use fructose as an added sweetener because it may adversely affect plasma lipids.[11][12] There is no minimum required amount of daily dietary carbohydrates as the body can make glucose through various metabolic processes including gluconeogenesis and glycogenolysis.[8] The same is not true of the protein and fat as both contain constituent components that are essential and cannot be synthesized through human metabolism.

The ADA also addresses the glycemic index and glycemic load of foods as they pertain to diabetics, but they decline to make specific recommendations due to the unclear clinical utility.[8] However, meta-analyses including the most recent Cochrane Systematic Review have found that a low glycemic index diet results in better blood glucose control as measured by glycated hemoglobin A1c (HbA1c) as well as fewer hypoglycemic episodes.[13][14]

Fiber

Benefits may be obtained by consumption of dietary fiber. There is some evidence that consuming dietary fiber my help control blood sugar levels; however, the ADA does not recommend any different goals for fiber intake for diabetics compared to non-diabetics.[8]

Fats

The ADA does not make a specific recommendation about the total amount of fat that should be consumed by diabetics on a daily basis.[8] They do note that studies have shown that high fat diets that have replaced carbohydrates with fat have shown improved glycemic control and improved blood lipid profiles (increased HDL concentration and decreased triglycerides) compared to low fat diets.[8] The ADA recommends avoiding all foods that have artificial sources of trans fats but note that the small amount of trans fats that naturally occur in meat and dairy are not a concern.[8]

Cholesterol

At this time the ADA does not have a specific recommendation for dietary cholesterol intake.[8] A causal link between dietary cholesterol consumption and cardiovascular disease has not been established.[8]

Low-carbohydrate diet

Further information: Low-carbohydrate diet § Diabetes
An example of a meal for diabetics on a low carbohydrate diet.

There is a lack of evidence of the usefulness of low-carbohydrate dieting for people with type 1 diabetes.[15] Although for certain individuals it may be feasible to follow a low-carbohydrate regime combined with carefully-managed insulin dosing, this is hard to maintain and there are concerns about potential adverse health effects caused by the diet.[15] In general people with type 1 diabetes are advised to follow an individualized eating plan rather than a pre-decided one.[15]

A low-carbohydrate diet gives slightly better control of glucose metabolism than a low-fat diet in type 2 diabetes.[16][17] A 2018 report on type 2 diabetes by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) found that a low-carbohydrate diet may not be as good as a Mediterranean diet at improving glycemic control, and that although having a healthy body weight is important, "there is no single ratio of carbohydrate, proteins, and fat intake that is optimal for every person with type 2 diabetes".[18]

The ADA say low-carbohydrate diets can be useful to help people with type 2 diabetes lose weight, but that these diets were poorly defined, difficult to sustain, unsuitable for certain groups of people and that, for diet composition in general, "no single approach has been proven to be consistently superior".[19] Overall, the ADA recommend people with diabetes should be "developing healthy eating patterns rather than focusing on individual macronutrients, micronutrients, or single foods". They recommended that the carbohydrate in a diet should come from "vegetables, legumes, fruits, dairy (milk and yogurt), and whole grains"; highly-refined foods and sugary drinks should be avoided.[19]

Vegan/vegetarian

An example of a high fiber vegan breakfast, suitable for someone suffering from Type 2 Diabetes.

According to The American Diabetes Association (ADA) a vegan diet is a healthful option for all ages.[20] In the ADA's 2018 Standards of Medical Care in Diabetes, a vegan diet was included as a treatment option.[21] Diabetes UK say that diabetes should not prevent people from going vegetarian and that it may be beneficial for people with diabetes to go vegetarian, as this will cut down on saturated fats.[22]

A meta analysis done in 2013 that compared a variety of different diets' effects on health concluded that a plant based diet high in whole foods, and with limited processed foods can be beneficial for the treatment and prevention of Type 2 Diabetes.[23]

Timing of meals

For people with diabetes, healthy eating is not simply a matter of "what one eats", but also when one eats. The question of how long before a meal one should inject insulin is asked in Sons Ken, Fox and Judd (1998). It depends upon the type one takes and whether it is long-, medium- or quick-acting insulin. If patients check their blood glucose at bedtime and find that it is low, for example below 6 millimoles per liter (108 mg/dL), it is advisable that they take some long-acting carbohydrate before retiring to bed to prevent night-time hypoglycemia. Night sweats, headaches, restless sleep, and nightmares can be a sign of nocturnal hypoglycemia, and patients should consult their doctor for adjustments to their insulin routine if they find that this is the case.[24] Counterintuitively, another possible sign of nocturnal hypoglycemia is morning hyperglycemia, which actually occurs in response to blood sugar getting too low at night. This is called the Somogyi effect.

In relation to type 2 diabetes, eating most food earlier in the day may be associated with lower levels of overweight and obesity and other factors that reduce the risk of developing type 2 diabetes.[25]

Special diabetes dietary products

Diabetes UK have warned against purchase of products that are specially made for people with diabetes, on grounds that:[26]

  • They may be expensive
  • They may contain high levels of fat
  • They may confer no special benefits to people who have diabetes

NICE (the National Institute for Health and Clinical Excellence in the United Kingdom) advises doctors and other health professionals to "Discourage the use of foods marketed specifically for people with diabetes".[27]

Alcohol and drugs

Moderation is advised with regard to consuming alcohol and using some drugs. Alcohol inhibits glycogenesis in the liver and some drugs inhibit hunger symptoms. This, with impaired judgment, memory and concentration caused by some drugs can lead to hypoglycemia. People with diabetes who take insulin or tablets such as sulphonylureas should not, therefore, consume alcohol on an empty stomach but take some starchy food (such as bread or potato crisps) at the same time as consumption of alcohol.[citation needed]

Specific diets

G.I. Diet: lowering the glycemic index of one's diet can improve the control of diabetes.[28][29] This includes avoidance of such foods as potatoes cooked in certain ways and white bread. It instead favors multi-grain and sourdough breads, legumes and whole grains that are converted more slowly to glucose in the bloodstream.

High fiber diet: It has been shown that a high fiber diet works better than the diet recommended by the American Diabetes Association in controlling diabetes and may control blood sugar levels with the same efficacy as oral diabetes drugs.[30][31][32] A low-fat vegan diet improves glycemic control similar to the ADA diet.[33]

The American Diabetes Association has endorsed a natural foods approach to managing diabetes, advocating “fresh is best” and avoiding artificial sweeteners, instead substituting measured amounts of fresh fruit or raw sugar.[34]

History

There has been long history of dietary treatment of diabetes mellitus. Dietary treatment of diabetes mellitus was used in Egypt since 3,500 BC[35][36] and was used in India by Sushruta and Charaka more than 2000 years ago.[35] In the 18th century, John Rollo argued that calorie restriction could reduce glycosuria in diabetes.[35]

More modern history of the diabetic diet may begin with Frederick Madison Allen and Elliott Joslin, who, in the early 20th century, before insulin was discovered, recommended that people with diabetes eat only a low-calorie and nearly zero-carbohydrate diet to prevent ketoacidosis from killing them. While this approach could extend life by a limited period, patients developed a variety of other medical problems.[37]

The introduction of insulin by Frederick Banting in 1922 allowed patients more flexibility in their eating.[37]

Exchange scheme

In the 1950s, the American Diabetes Association, in conjunction with the U.S. Public Health Service, introduced the "exchange scheme". This allowed people to swap foods of similar nutrition value (e.g., carbohydrate) for another. For example, if wishing to have more than normal carbohydrates for dessert, one could cut back on potatoes in one's first course. The exchange scheme was revised in 1976, 1986, and 1995.[38]

Later developments

Not all diabetes dietitians today recommend the exchange scheme. Instead, they are likely to recommend a typical healthy diet: one high in fiber, with a variety of fruit and vegetables, and low in both sugar and fat, especially saturated fat.

A diet high in plant fibre was recommended by James Anderson.[39] This may be understood as continuation of the work of Denis Burkitt and Hugh Trowell on dietary fibre,[40] which may be understood as a continuation of the work of Price.[41] It is still recommended that people with diabetes consume a diet that is high in dietary fiber.

In 1976, Nathan Pritikin opened a centre where patients were put on programme of diet and exercise (the Pritikin Program). This diet is high on carbohydrates and fibre, with fresh fruit, vegetables, and whole grains. A study at UCLA in 2005 showed that it brought dramatic improvement to a group of people with diabetes or pre-diabetes in three weeks, so that about half no longer met the criteria for the disease.[42][43][44][45]

See also

References

  1. ^ "Tips for Using the Diabetes Food Hub Meal Planner and Grocery List".
  2. ^ Katsilambros N, Liatis S, Makrilakis K (2006). Critical review of the international guidelines: what is agreed upon--what is not?. Nestlé Nutrition Workshop Series: Clinical & Performance Program. Vol. 11. pp. 207–18, discussion 218. doi:10.1159/000094453. ISBN 978-3-8055-8095-3. PMID 16820742. {{cite book}}: |journal= ignored (help)
  3. ^ Emadian A, Andrews RC, England CY, Wallace V, Thompson JL (November 2015). "The effect of macronutrients on glycaemic control: a systematic review of dietary randomised controlled trials in overweight and obese adults with type 2 diabetes in which there was no difference in weight loss between treatment groups". The British Journal of Nutrition. 114 (10): 1656–66. doi:10.1017/S0007114515003475. PMC 4657029. PMID 26411958.
  4. ^ Grams J, Garvey WT (June 2015). "Weight Loss and the Prevention and Treatment of Type 2 Diabetes Using Lifestyle Therapy, Pharmacotherapy, and Bariatric Surgery: Mechanisms of Action". Current Obesity Reports. 4 (2): 287–302. doi:10.1007/s13679-015-0155-x. PMID 26627223.
  5. ^ John McDougall Glycemic Index – Not Ready for Prime Time, The McDougall Newsletter, July 2006.
  6. ^ Segal-Isaacson CJ, Carello E, Wylie-Rosett J (October 2001). "Dietary fats and diabetes mellitus: is there a good fat?". Current Diabetes Reports. 1 (2): 161–9. doi:10.1007/s11892-001-0029-3. PMID 12643112. {{cite journal}}: Unknown parameter |agency= ignored (help)
  7. ^ "I have Type 1 diabetes - what can I eat?". Diabetes UK. Retrieved 14 June 2019.
  8. ^ a b c d e f g h i j Evert AB, Dennison M, Gardner CD, Garvey WT, Lau KH, MacLeod J, et al. (May 2019). "Nutrition Therapy for Adults With Diabetes or Prediabetes: A Consensus Report". Diabetes Care. 42 (5): 731–754. doi:10.2337/dci19-0014. PMID 31000505.
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  14. ^ Bashier, Alaaeldin; Bin Hussain, Azza; Abdelgadir, Elamin; Alawadi, Fatheya; Sabbour, Hani; Chilton, Robert (2019). "Consensus recommendations for management of patients with type 2 diabetes mellitus and cardiovascular diseases". Diabetology & Metabolic Syndrome. 11: 80. doi:10.1186/s13098-019-0476-0. ISSN 1758-5996. PMC 6761728. PMID 31572499.{{cite journal}}: CS1 maint: unflagged free DOI (link)
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  19. ^ a b American Diabetes Association Professional Practice Committee (January 2019). "Standards of Medical Care in Diabetes-2019". Diabetes Care. 42 (Suppl 1): S46–S60. doi:10.2337/dc19-S005. PMID 30559231.
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  27. ^ NICE Clinical Guideline CG87 Type 2 diabetes: The management of type 2 diabetes. http://publications.nice.org.uk/type-2-diabetes-cg87 Archived 2013-03-30 at the Wayback Machine
  28. ^ Brand-Miller J, Foster-Powell K, Nutr M, Brand-Miller J (1999). "Diets with a low glycemic index: from theory to practice". Nutrition Today. 34 (2): 64–72. doi:10.1097/00017285-199903000-00002.
  29. ^ Sheard NF, Clark NG, Brand-Miller JC, Franz MJ, Pi-Sunyer FX, Mayer-Davis E, et al. (September 2004). "Dietary carbohydrate (amount and type) in the prevention and management of diabetes: a statement by the american diabetes association". Diabetes Care. 27 (9): 2266–71. doi:10.2337/diacare.27.9.2266. PMID 15333500.
  30. ^ Chandalia M, Garg A, Lutjohann D, von Bergmann K, Grundy SM, Brinkley LJ (May 2000). "Beneficial effects of high dietary fiber intake in patients with type 2 diabetes mellitus". The New England Journal of Medicine. 342 (19): 1392–8. doi:10.1056/NEJM200005113421903. PMID 10805824.
  31. ^ Rodríguez-Morán M, Guerrero-Romero F, Lazcano-Burciaga G (1998). "Lipid- and glucose-lowering efficacy of Plantago Psyllium in type II diabetes". Journal of Diabetes and Its Complications. 12 (5): 273–8. doi:10.1016/S1056-8727(98)00003-8. PMID 9747644.
  32. ^ Schwartz SE, Levine RA, Weinstock RS, Petokas S, Mills CA, Thomas FD (December 1988). "Sustained pectin ingestion: effect on gastric emptying and glucose tolerance in non-insulin-dependent diabetic patients". The American Journal of Clinical Nutrition. 48 (6): 1413–7. doi:10.1093/ajcn/48.6.1413. PMID 2849298.
  33. ^ Barnard ND, Cohen J, Jenkins DJ, Turner-McGrievy G, Gloede L, Jaster B, et al. (August 2006). "A low-fat vegan diet improves glycemic control and cardiovascular risk factors in a randomized clinical trial in individuals with type 2 diabetes". Diabetes Care. 29 (8): 1777–83. doi:10.2337/dc06-0606. PMID 16873779. {{cite journal}}: Unknown parameter |lay-url= ignored (help); Unknown parameter |laydate= ignored (help); Unknown parameter |laysource= ignored (help)
  34. ^ Newgent 2007, pp. 1–5.
  35. ^ a b c Scaramuzza, de Beaufort & Hanas 2016, p. 91.
  36. ^ "History of Diabetes". Healthline. San Francisco: Healthline Media. 2012-01-26. Retrieved March 19, 2018.
  37. ^ a b Roberts, Jacob (2015). "Sickening sweet". Distillations. 1 (4): 12–15. Retrieved 20 March 2018.
  38. ^ Peterson, Amy Rachel; Chalmers, Karen Hanson (1999). 16 Myths of a Diabetic Diet. Alexandria, VA: American Diabetes Association. p. 85. ISBN 978-1-58040-031-2. {{cite book}}: Unknown parameter |name-list-format= ignored (|name-list-style= suggested) (help)
  39. ^ Anderson & Ward, 1979; cited in Murray & Pizzorno, 1990.
  40. ^ Trowell, Hugh C.; Burkett, Denis P. (1981). Western diseases: their emergence and prevention. Cambridge, MA: Harvard University Press. xiii–xvi. ISBN 978-0-674-95020-7. {{cite book}}: Unknown parameter |name-list-format= ignored (|name-list-style= suggested) (help); Unknown parameter |nopp= ignored (|no-pp= suggested) (help)
  41. ^ Murray & Pizzorno, 1990.
  42. ^ Booth FW, Chakravarthy MV (May 2006). "Physical activity and dietary intervention for chronic diseases: a quick fix after all?". Journal of Applied Physiology. 100 (5): 1439–40. doi:10.1152/japplphysiol.01586.2005. PMID 16614361.
  43. ^ Roberts CK, Won D, Pruthi S, Kurtovic S, Sindhu RK, Vaziri ND, Barnard RJ (May 2006). "Effect of a short-term diet and exercise intervention on oxidative stress, inflammation, MMP-9, and monocyte chemotactic activity in men with metabolic syndrome factors". Journal of Applied Physiology. 100 (5): 1657–65. doi:10.1152/japplphysiol.01292.2005. PMID 16357066.
  44. ^ Roberts CK, Barnard RJ (January 2005). "Effects of exercise and diet on chronic disease". Journal of Applied Physiology. 98 (1): 3–30. doi:10.1152/japplphysiol.00852.2004. PMID 15591300.
  45. ^ Bhattacharya, Shaoni (13 January 2006). "Three-week diet curbs diabetes". New Scientist. {{cite journal}}: Unknown parameter |name-list-format= ignored (|name-list-style= suggested) (help)


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