According to the ADA, all individuals with DM should be referred for individualized MNT provided by a registered dietitian nutritionist (RD/RDN) who is knowledgeable and skilled in providing diabetes-specific MNT (56) at diagnosis and as needed throughout the life span, similar to DSMES. MNT reduces A1c 1-1,9% in type 1 diabetes and 0,3-2% in type 2 diabetes.
Well, that's another pending subject in my clinical setting. Dietary advice in my hospital is delivered by the nurse educator, as part of DSMES program (see previous post about DSMES). No registered dietitian or nutritionist gives regular and structured dietary advice to diabetic patients at all, not only in my hospital, but in every hospital i know. I don't know, and haven't been able to find, how many patients with diabetes receive MNT from a registered dietitian.
Goals of nutrition therapy are attainment of desired weight, A1c, lipids and blood pressure according to management plan, and delay or prevent diabetic complications. It should be individualized, that is, having into account patient preferences, social background, food availability, and beliefs, restricting types or amounts of foods only when indicated by scientific evidence.
Different types of macronutrient distribution are acceptable, so the one that fits patient characteristics must be chosen. Mediterranean diet, vegan diet, or low-carb diet are examples of suitable meal plans.
WEIGHT MANAGEMENT
- Lifestyle modifications for all individuals with DM and overweight/obesity to achieve and attain 5% weight lose is recommended. A1c, lipids and BP benefit from 5% weight lose in most of these cases, althoug a larger weight reduction is associated to better outcomes.
CARBOHYDRATES
- CH sources should be minimally processed and high in fiber. Nonstarchy vegetables, fruits, dairy products, whole grains, and minimal added sugar is recommended.
- Reduced overall CH amount has the most evidence to improve glycemic control and can be applied to different eating patterns.
- In individuals with flexible insulin regimens, carbo counting to calculate meal insulin dosing is recommended, as well as, with lower level of evidence, fat and protein counting.
- On fixed insulin doses, adapt carb amount and timing to insulin action to reduce hypoglucemia and hyperglycemia.
- Both in diabetes and prediabetes, replace sugar-sweetened drinks with water to improve glycemia, weight, CV risk and fatty liver.
PROTEIN
- In type 2 diabetes, proteins increase insulin response to CH, so avoid foods rich in CH and proteins when treating hypoglycemia.
DIETARY FAT
- Mediterranean eating plan high in mono- and polyunsaturated fat improves glycemia and CV risk.
- Foods rich in n-3 fat like fish (eicosapentaenoic EPA, docosahexaenoic DHA) or nuts and seeds (alpha-linolenic ALA) reduce CV risk, but n-3 supplements are not recommended because evidence does not support a beneficial role.
- As to saturated, trans fat and cholesterol, follow recommendations for general population.
MICRONUTRIENTS
- In absence of documented deficiency, micronutrient, vitamins, herbs and other dietary supplements have no benefit in diabetes or CV disease.
ALCOHOL
- Alcohol consumers must do it in minimal quantities: one or two daily drinks in women and men respectively.
- Alcohol is associated to hypoglycemia, delayed hypoglycemia, weight gain and hyperglycemia.
SODIUM
- As for general population, limit sodium to <2.3 g daily.
NONCALORIC SWEETENERS
- They can reduce CH and total energy load if not replaced with other caloric foods, but water is better. For those used to sugar-sweetened drinks, they could be a short-term alternative, but again water is better.
