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Although most women with GDM revert to normal glucose tolerance postpartum, they are at increased risk of GDM in subsequent pregnancies and type 2 diabetes later in life. Individuals who have pre-diabetes or diabetes should receive individualized MNT; such therapy is best provided by a registered dietitian familiar with the components of diabetes MNT. The combustion of fossil fuels is a large human-initiated contributor to atmospheric nitrogen pollution. Providing supplementation To reduce child mortality, UNICEF supports vitamin A supplementation programmes for children aged months in priority countries those with high under-five mortality rates or where deficiencies are a public health problem. You are going to email the following Nutrition Recommendations and Interventions for Diabetes.
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High fiber and high fat ingredients increase caloric intake without increasing starch. This reduces excitability and heightened awareness allowing for a much cooler horse. All natural-source Vitamin E elevates plasma tocopherol more effectively than synthetic vitamin E which allows the horse to recover more quickly from soreness after strenuous exercise.
Due to the low starch nature of this feed it decreases the risk of insulin resistance by reducing the large fluctuations in glucose you would see in high starch feeds. In addition to increased requirements for minerals, vitamins and proteins, the older horse may be showing a significant loss of dental function. As a pelleted, textured feed, which contains high quality fiber, Equus 5 is designed to be easily chewed and digested by older horses.
The use of Soybean hulls in Equus 5 as a dietary fiber is also an alternative, safe, energy source, which leads to, improved senior horse performance. While energy intake is the most critical nutrient for horses working at high intensity, all nutrients are important for horses under extreme exercise stress. Equus Race addresses the nutrient needs for the race horse in a balanced way that insures that when fed with good hay, all requirements for energy, protein, minerals and vitamins are met.
In addition to being fully fortified with minerals and vitamins resulting in lower costs for owners and more accurate delivery of these nutrients, Equus Race features a balanced delivery of energy substrates. Equus Race features added fat, very soluble fiber in the form of beet pulp and starch from cereal grains. Chronic inflammation is activated when the mechanisms of acute inflammation fail to arrest infection or heal an injury. When unchecked, prolonged chronic inflammation generates a series of destructive reactions that damage cells and eventually lead to the clinical symptoms of disease.
Types of Immunity The human immune system provides two types of immunity that interact to defend the body against injury and infection: Innate immunity is triggered when a large sensor protein produced by bone marrow—an inflammasome—detects a toxic substance and stimulates defensive white cells known as macrophages to attack harmful cells. Adaptive immunity, sometimes referred to as acquired immunity, occurs when innate immunity fails to combat infection or injury.
The mechanisms of adaptive immunity are rooted in highly specialized responses to specific antigens. There are two types of adaptive immunity: Both B and T lymphocytes can divide and develop into effector cells, which detect and destroy infected cells. Unlike the innate immune system, the adaptive immune system produces memory cells that recognize and react to repeated exposures to specific antigens. The systems of innate and adaptive immunity work together to fight infection and protect the body from disease.
The following is a simplified explanation of their interaction Inflammation and Disease If the mechanisms of innate and adaptive immunity ineffectively combat an infection, prolonged inflammation can result in illness. The progression of chronic inflammation to disease is a complex process involving many different biological pathways.
Repeated or uncontrolled inflammatory processes unleash a host of defensive responses, including leukocyte proliferation, angiogenesis, oxidative reactions, and tissue fibrosis, that ultimately disturb the normal function of cells and set the stage for disease development. Inflammatory Processes The development of a specific disease depends on the site of the inflammatory response.
For example, disruption of the action of glomerular epithelial cells in the kidney results in renal disease, whereas damage to intestinal enterocytes leads to inflammatory bowel disease IBD.
Accelerated Cytokine Production Cytokines are small peptides that act as signaling systems within the body and affect many biological processes. Because they facilitate communication between the innate and adaptive immune systems, cytokines are a key factor in fighting infection and maintaining homeostasis. Proinflammatory cytokines such as interleukin 1 IL-1 and tumor necrosis factor alpha TNF-alpha are released defensively in response to infection and trauma.
Anti-inflammatory cytokines such as transforming growth factor beta TGF-beta and IL oppose the action of the proinflammatory cytokines and promote healing. An imbalance between the activity of proinflammatory and anti-inflammatory cytokines is believed to affect disease onset, course, and duration. Blood Concentration of Acute Phase Reactants The release of cytokines into the bloodstream signals the liver to produce a variety of proteins known as acute phase reactants APRs that respond to trauma or infection and serve as biomarkers of inflammation.
The body orchestrates a wide variety of these signaling pathways that often control more than one activity and engage in communication crosstalk with each other. For example, the cyclic adenosine monophosphate pathway responds to the effects of many hormones and neurotransmitters and helps regulate numerous biological processes, including glycogenolysis, lipogenesis, lipolysis, and neurotransmitter activity.
The NF-kB signaling pathway is an example of a proinflammatory signaling pathway that drives macrophages and neutrophils to respond to pathogens. Obesity Obesity is associated with an increased risk of many chronic disorders, including cardiovascular disease, diabetes, hypertension, metabolic syndrome, and nonalcoholic fatty liver disease, as well as numerous cancers eg, colorectal, gastric, esophageal, pancreatic, breast, endometrial, ovarian.
Adipose tissue is metabolically active and produces a variety of bioactive molecules called adipokines, which include hormones, proteins, growth factors, cytokines, and macrophages. Adipokines have numerous and far-reaching biological effects, including the regulation of food intake, energy expenditure, and glucose and fatty acid metabolism. An increase in abdominal fat causes adipose cells to grow and change shape, leading to cell necrosis and the disruption of adipokine activity.
Adipose tissue macrophages respond to increased fat cell mass by stimulating the secretion of the proinflammatory cytokines TNF-alpha, IL-6, and IL-1 beta, which in turn signal the liver to produce CRP and initiate inflammatory pathway signaling. Compared with normal-weight individuals, healthy obese people have higher circulating levels of proinflammatory cytokines and CRP.
Metabolic Syndrome Metabolic syndrome, which is recognized as a risk factor for cardiovascular disease and type 2 diabetes, is defined as the occurrence of three or more of the following conditions: Like obesity, metabolic syndrome is marked by chronic inflammation, resulting in high circulating levels of the proinflammatory cytokines TNF-alpha and IL-6, and elevated serum CRP levels.
Type 2 Diabetes Abdominal obesity is believed to be the source of the chronic inflammation that accompanies type 2 diabetes. Diabetes is accompanied by increased circulating levels of the proinflammatory cytokines TNF-alpha and IL-6 as well as decreased levels of the anti-inflammatory cytokine IL The net effect of these actions is hyperglycemia, increased insulin resistance, a higher risk of thrombosis, and abnormal lipoprotein metabolism.
Atherosclerosis Atherosclerosis once was believed to result simply from lipid accumulation in arterial walls.
Cardiovascular risk factors such as cigarette smoking, hypertension, and diets rich in trans fat stimulate endothelial cells within the artery to release a sticky protein called the vascular cell adhesion molecule, which causes leukocytes to bind to the arterial intima.
The continued depositing of white blood cells onto arterial cell walls stimulates the release of proinflammatory cytokines, which in turn cause macrophages called foam cells to engulf lipid fragments, leading to plaque formation and arterial damage. As damage to the arterial wall progresses, the cycle of inflammatory response intensifies, resulting in plaque instability and increasing the risk of aneurysm, stroke, or heart attack.
Cancer Chronic inflammation, infection, and tissue damage are associated with an increased risk of many types of cancer. For example, chronic infection with the human papilloma virus or hepatitis B or C virus may result in cervical and liver cancer, respectively, whereas Helicobacter pylori infection is a strong predictor of stomach cancer. During the normal healing process, macrophages help fight infection, repair damaged cells, and restore homeostasis.
Rheumatoid Arthritis Rheumatoid arthritis is an autoimmune disease marked by unrestrained growth of the synovial tissue of the joints, which leads to inflammation, pain, and joint damage. It develops when proteoglycans, structural proteins found in cartilage, act as antigens and stimulate T cells to produce various proinflammatory cytokines, such as TNF-alpha and IL-4, -5, and The production of these cytokines leads to joint swelling, pain, and eventual joint destruction.
In addition, T lymphocytes promote the activity of macrophages and B lymphocytes, which intensify the inflammatory response and hasten joint damage.
Nutrition and Inflammation Nutrients play a key role in both promoting and combating inflammatory processes. Evidence linking nutrients with inflammatory processes comes from laboratory, clinical, and epidemiologic studies.
Excessive energy intake stimulates adipose cell growth and proliferation, and promotes abdominal obesity, thereby increasing the risk of diabetes, metabolic syndrome, and other chronic diseases. Carbohydrate intake has been linked to chronic diseases such as obesity, metabolic syndrome, and type 2 diabetes.
Of particular interest are foods low in fiber and rich in sugars and starches, and those that produce a high glycemic value based on the glycemic index GI scale.
A prospective study conducted in Australia among postmenopausal women demonstrated that the risk of death from inflammatory disease, including digestive, respiratory, nervous system, and endocrine disorders, was nearly three times greater among women consuming a high-GI diet compared with women eating a low-GI diet.
Consuming trans fatty acids is a known risk factor for sudden cardiac death. A possible mechanism suggests that trans fatty acids induce an inflammatory response in cardiac tissue through their effect on cell membranes. Data from an in vitro study published in the British Journal of Nutrition showed that trans In addition, studies of patients with chronic heart failure have demonstrated significant associations between the trans fatty acid level of red blood cell membranes and plasma biomarkers of inflammation, including IL-1, IL-6, and TNF-alpha.
In vitro studies have shown that saturated fatty acids play a role in the inflammatory process by stimulating macrophage production and the secretion of the proinflammatory cytokines TNF-alpha, IL-6, and IL During the last several decades, the consumption of oils rich in the omega-6 fatty acid linoleic acid eg, soybean, corn, safflower, sunflower steadily has risen in the United States, resulting in an increased ratio of omega-6 to omega-3 fatty acids in the American diet.
Ideal dietary levels of omega-6 to omega-3 fatty acids are believed to be 1 to 4: This change has been associated with an increased risk of chronic inflammatory diseases, including atherosclerosis and cardiovascular disease, rheumatoid arthritis, and IBD. Omega-6 fatty acids are precursors to proinflammatory eicosanoids, signaling molecules that help regulate immune function and are active in the inflammatory process. These molecules have potent negative effects on platelet aggregation, blood pressure, and immune system function and trigger proinflammatory cytokine production.
The omega-3 fatty acids EPA and DHA, found in fatty fish and fish oil supplements, suppress the production of proinflammatory eicosanoids and stimulate the synthesis of anti-inflammatory eicosanoids lipoxins from arachadonic acid. Although most studies have focused on the effects of fish oil, consuming approximately 3 oz of fatty fish eg, salmon, herring five times per week for eight weeks resulted in significant lowering of plasma levels of proinflammatory cytokines TNF-alpha and IL-6 among elderly Chinese women with dyslipidemia.
Chia seed, walnuts, canola oil, and flaxseed oil are sources of the omega-3 fatty acid alpha-linolenic acid ALA. A powerful antioxidant, ascorbic acid vitamin C defends cells against lipid peroxidation and scavenges reactive oxygen and nitrogen species such as hydroxyl, peroxyl, superoxide, nitroxide radical, and peroxynitrite. Ascorbic acid supports phagocytosis by macrophages and stimulates the activity of natural killer lymphocytes generated during the innate immune response.
Through its function as a cofactor in enzymes controlling collagen synthesis, vitamin C also reduces tissue damage at inflammation sites. Vitamin E exists in nature as different chemical structures; the most common forms in the diet are alpha- and gamma-tocopherol.
Foods such as seeds, nuts, and vegetable oils are sources of gamma-tocopherol, while supplements commonly contain alpha-tocopherol. Alpha- and gamma-tocopherol have different biological activities. Alpha-tocopherol has long been recognized for its capacity to scavenge free radicals and prevent lipid oxidation.
In addition, it inhibits the release of proinflammatory cytokines and reduces CRP levels. Most clinical trials assessing the anti-inflammatory effects of vitamin E primarily have looked at alpha-tocopherol supplementation and not tocopherols from foods.
Alpha-tocopherol significantly decreases circulating levels of gamma-tocopherol, decreasing its anti-inflammatory properties. In addition, alpha- and gamma-tocopherol may have a synergistic effect on inflammation. Vitamin E shows some promise in the treatment of rheumatoid arthritis symptoms. These aromatic compounds are found in fruits, vegetables, grains, chocolate, coffee, olive oil, and tea.
To date, thousands of polyphenols have been identified and classified into different subgroups. Flavonoids include the flavanones naringenin and hesperidin found in citrus fruit ; flavonols such as myricetin, kaempferol, and quercetin found in apples, cocoa, and onions ; and the flavones luteolin and apigenin found in celery , catechins found in tea , and anthocyanins found in berries.
Phenolic acids caffeic acid, gallic acid, and ferulic acid are found in coffee, olive oil, tea, grains, peanuts, and berries. Lignans secoisolariciresinol and matairesinol are found primarily in flaxseeds. Therefore, protein should not be used to treat acute or prevent nighttime hypoglycemia. High-protein diets are not recommended as a method for weight loss at this time. Although such diets may produce short-term weight loss and improved glycemia, it has not been established that these benefits are maintained long term, and long-term effects on kidney function for persons with diabetes are unknown.
The RDA is 0. Good-quality protein sources are defined as having high PDCAAS protein digestibility—corrected amino acid scoring pattern scores and provide all nine indispensable amino acids. Examples are meat, poultry, fish, eggs, milk, cheese, and soy. In meal planning, protein intake should be greater than 0. A number of studies in healthy individuals and in individuals with type 2 diabetes have demonstrated that glucose produced from ingested protein does not increase plasma glucose concentration but does produce increases in serum insulin responses 1 , Abnormalities in protein metabolism may be caused by insulin deficiency and insulin resistance; however, these are usually corrected with good blood glucose control However, the effects of high-protein diets on long-term regulation of energy intake, satiety, weight, and the ability of individuals to follow such diets long term have not been adequately studied.
Dietary protein and its relationships to hypoglycemia and nephropathy are addressed in later sections. Although numerous studies have attempted to identify the optimal mix of macronutrients for the diabetic diet, it is unlikely that one such combination of macronutrients exists.
The best mix of carbohydrate, protein, and fat appears to vary depending on individual circumstances. For those individuals seeking guidance as to macronutrient distribution in healthy adults, the Dietary Reference Intakes DRIs may be helpful It must be clearly recognized that regardless of the macronutrient mix, total caloric intake must be appropriate to weight management goals.
Further, individualization of the macronutrient composition will depend on the metabolic status of the patient e. If adults with diabetes choose to use alcohol, daily intake should be limited to a moderate amount one drink per day or less for women and two drinks per day or less for men. To reduce risk of nocturnal hypoglycemia in individuals using insulin or insulin secretagogues, alcohol should be consumed with food.
In individuals with diabetes, moderate alcohol consumption when ingested alone has no acute effect on glucose and insulin concentrations but carbohydrate coingested with alcohol as in a mixed drink may raise blood glucose.
Abstention from alcohol should be advised for people with a history of alcohol abuse or dependence, women during pregnancy, and people with medical problems such as liver disease, pancreatitis, advanced neuropathy, or severe hypertriglyceridemia. If individuals choose to use alcohol, intake should be limited to a moderate amount less than one drink per day for adult women and less than two drinks per day for adult men. One alcohol containing beverage is defined as 12 oz beer, 5 oz wine, or 1.
Moderate amounts of alcohol, when ingested with food, have minimal acute effects on plasma glucose and serum insulin concentrations However, carbohydrate coingested with alcohol may raise blood glucose.
For individuals using insulin or insulin secretagogues, alcohol should be consumed with food to avoid hypoglycemia. Evening consumption of alcohol may increase the risk of nocturnal and fasting hypoglycemia, particularly in individuals with type 1 diabetes Occasional use of alcoholic beverages should be considered an addition to the regular meal plan, and no food should be omitted.
Excessive amounts of alcohol three or more drinks per day , on a consistent basis, contributes to hyperglycemia In individuals with diabetes, light to moderate alcohol intake one to two drinks per day; 15—30 g alcohol is associated with a decreased risk of CVD The type of alcohol-containing beverage consumed does not appear to make a difference. There is no clear evidence of benefit from vitamin or mineral supplementation in people with diabetes compared with the general population who do not have underlying deficiencies.
Routine supplementation with antioxidants, such as vitamins E and C and carotene, is not advised because of lack of evidence of efficacy and concern related to long-term safety. Benefit from chromium supplementation in individuals with diabetes or obesity has not been clearly demonstrated and therefore can not be recommended. Uncontrolled diabetes is often associated with micronutrient deficiencies Individuals with diabetes should be aware of the importance of acquiring daily vitamin and mineral requirements from natural food sources and a balanced diet.
Health care providers should focus on nutrition counseling rather than micronutrient supplementation in order to reach metabolic control of their patients. Research including long-term trials is needed to assess the safety and potentially beneficial role of chromium, magnesium, and antioxidant supplements and other complementary therapies in the management of type 2 diabetes 71a , 71b.
In select groups such as the elderly, pregnant or lactating women, strict vegetarians, or those on calorie-restricted diets, a multivitamin supplement may be needed 1. Since diabetes may be a state of increased oxidative stress, there has been interest in antioxidant therapy. Unfortunately, there are no studies examining the effects of dietary intervention on circulating levels of antioxidants and inflammatory biomarkers in diabetic volunteers.
The few small clinical studies involving diabetes and functional foods thought to have high antioxidant potential e. Clinical trial data not only indicate the lack of benefit with respect to glycemic control and progression of complications but also provide evidence of the potential harm of vitamin E, carotene, and other antioxidant supplements 1 , 72 , In addition, available data do not support the use of antioxidant supplements for CVD risk reduction Chromium, potassium, magnesium, and possibly zinc deficiency may aggravate carbohydrate intolerance.
Serum levels can readily detect the need for potassium or magnesium replacement, but detecting deficiency of zinc or chromium is more difficult In the late s, two randomized placebo-controlled studies in China found that chromium supplementation had beneficial effects on glycemia 76 — 78 , but the chromium status of the study populations was not evaluated either at baseline or following supplementation.
Data from recent small studies indicate that chromium supplementation may have a role in the management of glucose intolerance, gestational diabetes mellitus GDM , and corticosteroid-induced diabetes 76 — However, other well-designed studies have failed to demonstrate any significant benefit of chromium supplementation in individuals with impaired glucose intolerance or type 2 diabetes 79 , Similarly, a meta-analysis of randomized controlled trials failed to demonstrate any benefit of chromium picolinate supplementation in reducing body weight The FDA concluded that although a small study suggested that chromium picolinate may reduce insulin resistance, the existence of such a relationship between chromium picolinate and either insulin resistance or type 2 diabetes was uncertain http: There is insufficient evidence to demonstrate efficacy of individual herbs and supplements in diabetes management In addition, commercially available products are not standardized and vary in the content of active ingredients.
Herbal preparations also have the potential to interact with other medications Therefore, it is important that health care providers be aware when patients with diabetes are using these products and look for unusual side effects and herb-drug or herb-herb interactions. Individuals using rapid-acting insulin by injection or an insulin pump should adjust the meal and snack insulin doses based on the carbohydrate content of the meals and snacks.
For individuals using fixed daily insulin doses, carbohydrate intake on a day-to-day basis should be kept consistent with respect to time and amount. For planned exercise, insulin doses can be adjusted.
For unplanned exercise, extra carbohydrate may be needed. The first nutrition priority for individuals requiring insulin therapy is to integrate an insulin regimen into their lifestyle. For individuals receiving basal-bolus insulin therapy, the total carbohydrate content of meals and snacks is the major determinant of bolus insulin doses Insulin-to-carbohydrate ratios can be used to adjust mealtime insulin doses.
Several methods can be used to estimate the nutrient content of meals, including carbohydrate counting, the exchange system, and experience-based estimation. Improvement in A1C without a significant increase in severe hypoglycemia was demonstrated, as were positive effects on quality of life, satisfaction with treatment, and psychological well-being, even though increases in the number of insulin injections and blood glucose tests were necessary.
For planned exercise, reduction in insulin dosage is the preferred method to prevent hypoglycemia For unplanned exercise, intake of additional carbohydrate is usually needed. More carbohydrate is needed for intense activity. A American Diabetes Association statement addresses diabetes MNT for children and adolescents with type 1 diabetes Individuals with type 2 diabetes are encouraged to implement lifestyle modifications that reduce intakes of energy, saturated and trans fatty acids, cholesterol, and sodium and to increase physical activity in an effort to improve glycemia, dyslipidemia, and blood pressure.
Plasma glucose monitoring can be used to determine whether adjustments in foods and meals will be sufficient to achieve blood glucose goals or if medication s needs to be combined with MNT. Healthy lifestyle nutrition recommendations for the general public are also appropriate for individuals with type 2 diabetes. Because many individuals with type 2 diabetes are overweight and insulin resistant, MNT should emphasize lifestyle changes that result in reduced energy intake and increased energy expenditure through physical activity.
Because many individuals also have dyslipidemia and hypertension, reducing saturated and trans fatty acids, cholesterol, and sodium is often desirable. Therefore, the first nutrition priority is to encourage individuals with type 2 diabetes to implement lifestyle strategies that will improve glycemia, dyslipidemia, and blood pressure. Although there are similarities to those above for type 1 diabetes, MNT recommendations for established type 2 diabetes differ in several aspects from both recommendations for type 1 diabetes and the prevention of diabetes.
MNT progresses from prevention of overweight and obesity, to improving insulin resistance and preventing or delaying the onset of diabetes, and to contributing to improved metabolic control in those with diabetes. With established type 2 diabetes treated with fixed doses of insulin or insulin secretagogues, consistency in timing and carbohydrate content of meals is important. However, rapid-acting insulins and rapid-acting insulin secretagogues allow for more flexible food intake and lifestyle as in individuals with type 1 diabetes.
Increased physical activity by individuals with type 2 diabetes can lead to improved glycemia, decreased insulin resistance, and a reduction in cardiovascular risk factors, independent of change in body weight. Resistance training is also effective in improving glycemia and, in the absence of proliferative retinopathy, people with type 2 diabetes can be encouraged to perform resistance exercise three times a week Adequate energy intake that provides appropriate weight gain is recommended during pregnancy.
Weight loss is not recommended; however, for overweight and obese women with GDM, modest energy and carbohydrate restriction may be appropriate. MNT for GDM focuses on food choices for appropriate weight gain, normoglycemia, and absence of ketones.
Because GDM is a risk factor for subsequent type 2 diabetes, after delivery, lifestyle modifications aimed at reducing weight and increasing physical activity are recommended.
Prepregnancy MNT includes an individualized prenatal meal plan to optimize blood glucose control. Due to the continuous fetal draw of glucose from the mother, maintaining consistency of times and amounts of food eaten are important to avoidance of hypoglycemia. Plasma glucose monitoring and daily food records provide valuable information for insulin and meal plan adjustments. MNT for GDM primarily involves a carbohydrate-controlled meal plan that promotes optimal nutrition for maternal and fetal health with adequate energy for appropriate gestational weight gain, achievement and maintenance of normoglycemia, and absence of ketosis.
Specific nutrition and food recommendations are determined and subsequently modified based on individual assessment and self-monitoring of blood glucose. A recent large clinical trial reported that treatment of GDM with nutrition therapy, blood glucose monitoring, and insulin therapy as required for glycemic control reduced serious perinatal complications without increasing the rate of cesarean delivery as compared with routine care Maternal health—related quality of life was also improved.
Hypocaloric diets in obese women with GDM can result in ketonemia and ketonuria. Insufficient data are available to determine how such diets affect perinatal outcomes. Daily food records, weekly weight checks, and ketone testing can be used to determine individual energy requirements and whether a woman is undereating to avoid insulin therapy.
Carbohydrate should be distributed throughout the day in three small- to moderate-sized meals and two to four snacks. An evening snack may be needed to prevent accelerated ketosis overnight. Carbohydrate is generally less well tolerated at breakfast than at other meals. Regular physical activity can help lower fasting and postprandial plasma glucose concentrations and may be used as an adjunct to improve maternal glycemia.
If insulin therapy is added to MNT, maintaining carbohydrate consistency at meals and snacks becomes a primary goal. Although most women with GDM revert to normal glucose tolerance postpartum, they are at increased risk of GDM in subsequent pregnancies and type 2 diabetes later in life. Lifestyle modifications after pregnancy aimed at reducing weight and increasing physical activity are recommended, as they reduce the risk of subsequent diabetes 26 , Breast-feeding is recommended for infants of women with preexisting diabetes or GDM; however, successful lactation requires planning and coordination of care In most situations, breast-feeding mothers require less insulin because of the calories expended with nursing.
Lactating women have reported fluctuations in blood glucose related to nursing sessions, often requiring a snack containing carbohydrate before or during breast-feeding Obese older adults with diabetes may benefit from modest energy restriction and an increase in physical activity; energy requirement may be less than for a younger individual of a similar weight. A daily multivitamin supplement may be appropriate, especially for those older adults with reduced energy intake.
Physical activity is needed to attenuate loss of lean body mass that can occur with energy restriction. Exercise training can significantly reduce the decline in maximal aerobic capacity that occurs with age, improve risk factors for atherosclerosis, slow the age-related decline in lean body mass, decrease central adiposity, and improve insulin sensitivity—all potentially beneficial for the older adult with diabetes 89 , However, exercise can also pose potential risks such as cardiac ischemia, musculoskeletal injuries, and hypoglycemia in patients treated with insulin or insulin secretagogues.
Reduction of protein intake to 0. MNT that favorably affects cardiovascular risk factors may also have a favorable effect on microvascular complications such as retinopathy and nephropathy. Progression of diabetes complications may be modified by improving glycemic control, lowering blood pressure, and, potentially, reducing protein intake.
In several studies of subjects with diabetes and microalbuminuria, urinary albumin excretion rate and decline in glomerular filtration were favorably influenced by reduction of protein intake to 0. Although reduction of protein intake to 0.
In individuals with diabetes and macroalbuminuria, reducing protein from all sources to 0. Although several studies have explored the potential benefit of plant proteins in place of animal proteins and specific animal proteins in diabetic individuals with microalbuninuria, the data are inconclusive 1 , Observational data suggest that dyslipidemia may increase albumin excretion and the rate of progression of diabetic nephropathy Elevation of plasma cholesterol in both type 1 and 2 diabetic subjects and plasma triglycerides in type 2 diabetic subjects were predictors of the need for renal replacement therapy Whereas these observations do not confirm that MNT will affect diabetic nephropathy, MNT designed to reduce the risk for CVD may have favorable effects on microvascular complications of diabetes.
For patients with diabetes at risk for CVD, diets high in fruits, vegetables, whole grains, and nuts may reduce the risk. In normotensive and hypertensive individuals, a reduced sodium intake e. In most individuals, a modest amount of weight loss beneficially affects blood pressure. In the EDIC Epidemiology of Diabetes Interventions and Complications study, the follow-up of the DCCT Diabetes Control and Complications Trial , intensive treatment of type 1 diabetic subjects during the DCCT study period improved glycemic control and significantly reduced the risk of the combined end point of cardiovascular death, myocardial infarction, and stroke Adjustment for A1C explained most of the treatment effect.
The risk reductions obtained with improved glycemia exceeded those that have been demonstrated for other interventions such as cholesterol and blood pressure reductions.
There are no large-scale randomized trials to guide MNT recommendations for CVD risk reduction in individuals with type 2 diabetes. However, because CVD risk factors are similar in individuals with and without diabetes, benefits observed in nutrition studies in the general population are probably applicable to individuals with diabetes. The previous section on dietary fat addresses the need to reduce intake of saturated and trans fatty acids and cholesterol.
Hypertension, which is predictive of progression of micro- as well as macrovascular complications of diabetes, can be prevented and managed with interventions including weight loss, physical activity, moderation of alcohol intake, and diets such as DASH Dietary Approaches to Stop Hypertension.
The DASH diet emphasized fruits, vegetables, and low-fat dairy products; included whole grains, poultry, fish, and nuts; and was reduced in fats, red meat, sweets, and sugar-containing beverages 7 , , The effects of lifestyle interventions on hypertension appear to be additive.
Reduction in blood pressure in people with diabetes can occur with a modest amount of weight loss, although there is great variability in response 1 , 7. Regular aerobic physical activity, such as brisk walking, has an antihypertensive effect 7. Although chronic excessive alcohol intake is associated with an increased risk of hypertension, light to moderate alcohol consumption is associated with reductions in blood pressure 7.
Heart failure and peripheral vascular disease are common in individuals with diabetes, but little is known about the role of MNT in treating these complications. Alcohol intake is discouraged in patients at high risk for heart failure.
Ingestion of 15—20 g glucose is the preferred treatment for hypoglycemia, although any form of carbohydrate that contains glucose may be used. In individuals taking insulin or insulin secretagogues, changes in food intake, physical activity, and medication can contribute to the development of hypoglycemia. The acute glycemic response correlates better with the glucose content than with the carbohydrate content of the food 1.
Although pure glucose may be the preferred treatment, any form of carbohydrate that contains glucose will raise blood glucose Adding protein to carbohydrate does not affect the glycemic response and does not prevent subsequent hypoglycemia.
Adding fat, however, may retard and then prolong the acute glycemic response. During hypoglycemia, gastric-emptying rates are twice as fast as during euglycemia and are similar for liquid and solid foods. During acute illnesses, insulin and oral glucose-lowering medications should be continued. During acute illnesses, testing of plasma glucose and ketones, drinking adequate amounts of fluids, and ingesting carbohydrate are all important.
Acute illnesses can lead to the development of hyperglycemia and, in individuals with type 1 diabetes, ketoacidosis. During acute illnesses, with the usual accompanying increases in counterregulatory hormones, the need for insulin and oral glucose-lowering medications continues and often is increased. In adults, ingestion of — g carbohydrate daily 45—50 g every 3—4 h should be sufficient to prevent starvation ketosis 1. Establishing an interdisciplinary team, implementation of MNT, and timely diabetes-specific discharge planning improves the care of patients with diabetes during and after hospitalizations.
Hospitals should consider implementing a diabetes meal-planning system that provides consistency in the carbohydrate content of specific meals. Hyperglycemia in hospitalized patients is common and represents an important marker of poor clinical outcome and mortality in both patients with and without diabetes Optimizing glucose control in these patients is associated with better outcomes An interdisciplinary team is needed to integrate MNT into the overall management plan , Diabetes nutrition self-management education, although potentially initiated in the hospital, is usually best provided in an outpatient or home setting where the individual with diabetes is better able to focus on learning needs , There is no single meal planning system that is ideal for hospitalized patients.
However, it is suggested that hospitals consider implementing a consistent-carbohydrate diabetes meal-planning system , This systems uses meal plans without a specific calorie level but consistency in the carbohydrate content of meals. The carbohydrate contents of breakfast, lunch, dinner, and snacks may vary, but the day-to-day carbohydrate content of specific meals and snacks is kept constant , Special nutrition issues include liquid diets, surgical diets, catabolic illnesses, and enteral or parenteral nutrition , Liquids should not be sugar free.
Patients require carbohydrate and calories, and sugar-free liquids do not meet these nutritional needs. Care must be taken not to overfeed patients because this can exacerbate hyperglycemia. After surgery, food intake should be initiated as quickly as possible. Progression from clear liquids to full liquids to solid foods should be completed as rapidly as tolerated. The imposition of dietary restrictions on elderly patients with diabetes in long-term care facilities is not warranted.
Residents with diabetes should be served a regular menu, with consistency in the amount and timing of carbohydrate. An interdisciplinary team approach is necessary to integrate MNT for patients with diabetes into overall management.
In the institutionalized elderly, undernutrition is likely and caution should be exercised when prescribing weight loss diets. Although the prevalence of undiagnosed diabetes in elderly nursing home residents is high, not all of such individuals require pharmacologic therapy , Older residents with diabetes in nursing homes tend to be underweight rather than overweight Low body weight has been associated with greater morbidity and mortality in this population , Experience has shown that residents eat better when they are given less restrictive diets , Specialized diabetic diets do not appear to be superior to standard diets in such settings , Meal plans such as no concentrated sweets, no sugar added, low sugar, and liberal diabetic diet also are no longer appropriate.
These diets do not reflect current diabetes nutrition recommendations and unnecessarily restrict sucrose. These types of diets are more likely in long-term care facilities than acute care. Making medication changes to control glucose, lipids, and blood pressure rather than implementing food restrictions can reduce the risk of iatrogenic malnutrition. The specific nutrition interventions recommended will depend on a variety of factors, including age, life expectancy, comorbidities, and patient preferences Major nutrition recommendations and interventions for diabetes are listed in Table 3.
Monitoring of metabolic parameters, including glucose, A1C, lipids, blood pressure, body weight, and renal function is essential to assess the need for changes in therapy and to ensure successful outcomes. Many aspects of MNT require additional research. Classification of overweight and obesity by BMI, waist circumference, and associated disease risk.
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We do not capture any email address. Skip to main content. Diabetes Care Jan; 31 Supplement 1: This article has a correction. Errata - August 01, Department of Agriculture Medical nutrition therapy MNT is important in preventing diabetes, managing existing diabetes, and preventing, or at least slowing, the rate of development of diabetes complications. Goals of MNT that apply to individuals with diabetes Achieve and maintain Blood glucose levels in the normal range or as close to normal as is safely possible A lipid and lipoprotein profile that reduces the risk for vascular disease Blood pressure levels in the normal range or as close to normal as is safely possible To prevent, or at least slow, the rate of development of the chronic complications of diabetes by modifying nutrient intake and lifestyle To address individual nutrition needs, taking into account personal and cultural preferences and willingness to change To maintain the pleasure of eating by only limiting food choices when indicated by scientific evidence Goals of MNT that apply to specific situations For youth with type 1 diabetes, youth with type 2 diabetes, pregnant and lactating women, and older adults with diabetes, to meet the nutritional needs of these unique times in the life cycle.
B Nutrition counseling should be sensitive to the personal needs, willingness to change, and ability to make changes of the individual with pre-diabetes or diabetes. A For weight loss, either low-carbohydrate or low-fat calorie-restricted diets may be effective in the short term up to 1 year.
A For patients on low-carbohydrate diets, monitor lipid profiles, renal function, and protein intake in those with nephropathy , and adjust hypoglycemic therapy as needed. E Physical activity and behavior modification are important components of weight loss programs and are most helpful in maintenance of weight loss. B The importance of controlling body weight in reducing risks related to diabetes is of great importance.