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Nutrition Recommendations andInterventions for Diabetes
 A position statement of the American Diabetes Association
A
MERICAN
D
IABETES
A
SSOCIATION
M
edical nutrition therapy (MNT) isimportant in preventing diabetes,managing existing diabetes, andpreventing, or at least slowing, the rate of developmentofdiabetescomplications.Itis, therefore, important at all levels of di-abetes prevention (see Table 1). MNT isalso an integral component of diabetesself-management education (or training).This position statement provides evi-dence-basedrecommendationsandinter-ventions for diabetes MNT. The previousposition statement with accompanyingtechnical review was published in 2002(1)andmodifiedslightlyin2004(2).Thisstatement updates previous positionstatements, focuses on key referencespublished since the year 2000, and usesgrading according to the level of evidenceavailable based on the American Diabetes Association evidence-grading system.Since overweight and obesity are closelylinked to diabetes, particular attention ispaid to this area of MNT.Thegoaloftheserecommendationsisto make people with diabetes and healthcare providers aware of beneficial nutri-tion interventions. This requires the useof the best available scientific evidencewhiletakingintoaccounttreatmentgoals,strategies to attain such goals, andchanges individuals with diabetes arewilling and able to make. Achieving nu-trition-related goals requires a coordi-natedteameffortthatincludesthepersonwith diabetes and involves him or her inthe decision-making process. It is recom-mendedthataregistereddietitian,knowl-edgeable and skilled in MNT, be the teammember who plays the leading role inproviding nutrition care. However, it isimportant that all team members, includ-ingphysiciansandnurses,beknowledge-able about MNT and support itsimplementation.MNT,asillustratedinTable1,playsarole in all three levels of diabetes-relatedprevention targeted by the U.S. Depart-ment of Health and Human Services. Pri-mary prevention interventions seek todelayorhaltthedevelopmentofdiabetes.This involves public health measures toreduce the prevalence of obesity and in-cludes MNT for individuals with pre-diabetes.Secondaryandtertiarypreventioninterventions include MNT for individualswith diabetes and seek to prevent (sec-ondary) or control (tertiary) complica-tions of diabetes.
GOALS OF MNT FOR PREVENTION ANDTREATMENT OF DIABETES
Goals of MNT that apply toindividuals at risk for diabetes or with pre-diabetes
To decrease the risk of diabetes and car-diovascular disease (CVD) by promotinghealthy foodchoicesandphysical activityleading to moderate weight loss that ismaintained.
Goals of MNT that apply toindividuals with diabetes
1
) Achieve and maintain
●
Blood glucose levels in the normalrange or as close to normal as is safelypossible
●
A lipid and lipoprotein profile that re-duces the risk for vascular disease
●
Blood pressure levels in the normalrange or as close to normal as is safelypossible
 2
) To prevent, or at least slow, the rate of development of the chronic complica-tions of diabetes by modifying nutrientintake and lifestyle
3
) To address individual nutrition needs,taking into account personal and culturalpreferences and willingness to change
4
) To maintain the pleasure of eating byonlylimitingfoodchoiceswhenindicatedby scientific evidence
Goals of MNT that apply to specificsituations
1
) For youth with type 1 diabetes, youthwith type 2 diabetes, pregnant and lactat-ing women, and older adults with diabe-tes, to meet the nutritional needs of theseunique times in the life cycle.
 2
) For individuals treated with insulin orinsulin secretagogues, to provide self-management training for safe conduct of exercise, including the prevention andtreatment of hypoglycemia, and diabetestreatment during acute illness.
EFFECTIVENESS OF MNT
Recommendations
●
Individuals who have pre-diabetes ordiabetes should receive individualizedMNT; such therapy is best provided bya registered dietitian familiar with thecomponents of diabetes MNT. (B)
●
Nutrition counseling should be sensi-tive to the personal needs, willingnessto change, and ability to make changesof the individual with pre-diabetes ordiabetes. (E)Clinical trials/outcome studies of MNT have reported decreases in HbA
1c
(A1C) of 
1% in type 1 diabetes and1–2% in type 2 diabetes, depending onthe duration of diabetes (3,4). Meta-analysis of studies in nondiabetic, free-living subjects and expert committeesreport that MNT reduces LDL cholesterolby 15–25 mg/dl (5,6). After initiation of MNT, improvements were apparent in3–6 months. Meta-analysis and expertcommitteesalsosupportaroleforlifestylemodification in treating hypertension(7,8).
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
Originally approved 2006. Revised 2007. Writing panel: John P. Bantle (Co-Chair), Judith Wylie-Rosett (Co-Chair), Ann L. Albright, Caroline M. Apovian, Nathaniel G. Clark, Marion J. Franz, Byron J. Hoogwerf, Alice H. Lichtenstein, Elizabeth Mayer-Davis, Arshag D. Mooradian, and Madelyn L. Wheeler.
Abbreviations:
CHD,coronaryheartdisease;CKD,chronickidneydisease;CVD,cardiovasculardisease;DPP, Diabetes Prevention Program; FDA, Food and Drug Administration; GDM, gestational diabetes mel-litus; MNT, medical nutrition therapy; RDA, recommended dietary allowance; USDA, U.S. Department of  Agriculture.DOI: 10.2337/dc08-S061© 2008 by the American Diabetes Association.
P O S I T I O N S T A T E M E N T
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2008
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ENERGY BALANCE,OVERWEIGHT, ANDOBESITY 
Recommendations
●
In overweight and obese insulin-resistant individuals, modest weightlosshasbeenshowntoimproveinsulinresistance. Thus, weight loss is recom-mended for all such individuals whohave or are at risk for diabetes. (A)
●
For weight loss, either low-carbohy-drate or low-fat calorie-restricted dietsmaybeeffectiveintheshortterm(upto1 year). (A)
●
Forpatientsonlow-carbohydratediets,monitor lipid profiles, renal function,and protein intake (in those with ne-phropathy), and adjust hypoglycemictherapy as needed. (E)
●
Physical activity and behavior modifi-cation are important components of weight loss programs and are mosthelpful in maintenance of weight loss.(B)
●
Weight loss medications may be con-sidered in the treatment of overweightand obese individuals with type 2 dia-betes and can help achieve a 5–10%weight loss when combined with life-style modification. (B)
●
Bariatric surgery may be considered forsome individuals with type 2 diabetesand BMI
35 kg/m
2
and can result inmarked improvements in glycemia.The long-term benefits and risks of bariatric surgery in individuals withpre-diabetes or diabetes continue to bestudied. (B)The importance of controlling bodyweight in reducing risks related to diabe-tes is of great importance. Therefore,these nutrition recommendations start byconsidering energy balance and weightloss strategies. The National Heart, Lung,and Blood Institute guidelines defineoverweight as BMI
25 kg/m
2
and obe-sity as BMI
30 kg/m
2
(9). The risk of comorbidity associated with excess adi-pose tissue increases with BMIs in thisrange and above. However, cliniciansshould be aware that in some Asian pop-ulations, the proportion of people at highrisk of type 2 diabetes and CVD is signif-icant at BMIs of 
23 kg/m
2
(10). Visceralbodyfat,asmeasuredbywaistcircumfer-ence
35 inches in women and
40inches in men, is used in conjunctionwith BMI to assess risk of type 2 diabetesand CVD (Table 2) (9). Lower waist cir-cumference cut points (
31 inches inwomen,
35 inches in men) may be ap-propriate for Asian populations (11).Because of the effects of obesity oninsulin resistance, weight loss is an im-portant therapeutic objective for individ-uals with pre-diabetes or diabetes (12).However, long-term weight loss is diffi-cultformostpeopletoaccomplish.Thisisprobablybecausethecentralnervoussys-tem plays an important role in regulatingenergy intake and expenditure. Short-term studies have demonstrated thatmoderateweightloss(5%ofbodyweight)in subjects with type 2 diabetes is associ-ated with decreased insulin resistance,improved measures of glycemia and li-pemia, and reduced blood pressure (13).Longer-term studies (
52 weeks) usingpharmacotherapyforweightlossinadultswithtype2diabetesproducedmodestre-ductions in weight and A1C (14), al-thoughimprovementinA1Cwasnotseenin all studies (15,16). Look AHEAD (Ac-tion for Health in Diabetes) is a large Na-tional Institutes of Health–sponsoredclinical trial designed to determine if long-term weight loss will improve glyce-mia and prevent cardiovascular events(17). When completed, this study shouldprovide insight into the effects of long-term weight loss on important clinicaloutcomes.Evidence demonstrates that struc-tured,intensivelifestyleprogramsinvolv-ing participant education, individualizedcounseling, reduced dietary energy andfat (
30% of total energy) intake, regularphysicalactivity,andfrequentparticipantcontact are necessary to produce long-term weight loss of 5–7% of startingweight (1). The role of lifestyle modifica-tion in the management of weight andtype 2 diabetes was recently reviewed(13). Although structured lifestyle pro-grams have been effective when deliveredinwell-fundedclinicaltrials,itisnotclearhow the results should be translated intoclinical practice. Organization, delivery,and funding of lifestyle interventions areall issues that must be addressed. Third-party payers may not provide adequatebenefitsforsufficientMNTfrequencyandtime to achieve weight loss goals (18).Exercise and physical activity, bythemselves, have only a modest weightloss effect. However, exercise and physi-cal activity are to be encouraged becausethey improve insulin sensitivity indepen-dent of weight loss, acutely lower bloodglucose, and are important in long-termmaintenance of weight loss (1). Weightloss with behavioral therapy alone alsohas been modest, and behavioral ap-proaches may be most useful as an ad- junct to other weight loss strategies.Standard weight loss diets provide
Table 1—
Nutrition and MNT
Primary prevention to prevent diabetes: Secondary prevention to prevent complications: Tertiary prevention to prevent morbidity and mortality:
●
Use MNT and public healthinterventions in those with obesityand pre-diabetes
●
Use MNT for metabolic control of diabetes
●
Use MNT to delay and manage complications of diabetes
Table 2—
Classification of overweight and obesity by BMI, waist circumference, and associ-ated disease risk
BMI (kg/m
2
)ObesityclassDisease risk* WC: men
40 inches;women
35 inches WC: men
40inches; women
35 inchesUnderweight
18.5Normal 18.5–24.9Overweight 25.0–29.9 Increased HighObesity 30.0–34.9 I High Very high35.0–39.9 II Very high Very highExtreme obesity
40 III Extremely high Extremely high
*Disease risk for type 2 diabetes, hypertension, and CVD. Adapted from ref. 9. WC, waist circumference.
Nutrition recommendations and interventions
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500–1,000 fewer calories than estimatedto be necessary for weight maintenanceand initially result in a loss of 
1–2 lb/ week. Although many people can losesome weight (as much as 10% of initialweight in
6 months) with such diets,without continued support and follow-up, people usually regain the weight theyhave lost.The optimal macronutrient distri-bution of weight loss diets has not beenestablished.Althoughlow-fatdietshavetraditionally been promoted for weightloss, two randomized controlled trialsfound that subjects on low-carbohy-drate diets lost more weight at 6 monthsthan subjects on low-fat diets (19,20). Another study of overweight womenrandomized to one of four diets showedsignificantly more weight loss at 12months with the Atkins low-carbohy-drate diet than with higher-carbohy-drate diets (20a). However, at 1 year,the difference in weight loss betweenthe low-carbohydrate and low-fat dietswas not significant and weight loss wasmodest with both diets. Changes in se-rum triglyceride and HDL cholesterolwere more favorable with the low-carbohydrate diets. In one study, thosesubjects with type 2 diabetes demon-strated a greater decrease in A1C with alow-carbohydrate diet than with a low-fat diet (20). A recent meta-analysisshowed that at 6 months, low-carbohydrate diets were associated withgreater improvements in triglycerideand HDL cholesterol concentrationsthan low-fat diets; however, LDL cho-lesterol was significantly higher on thelow-carbohydrate diets (21). Furtherresearch is needed to determine thelong-term efficacy and safety of low-carbohydrate diets (13). The recom-mended dietary allowance (RDA) fordigestible carbohydrate is 130 g/dayand is based on providing adequate glu-cose as the required fuel for the centralnervous system without reliance on glu-cose production from ingested proteinor fat (22). Although brain fuel needscan be met on lower-carbohydrate di-ets, long-term metabolic effects of very-low-carbohydrate diets are unclear, andsuch diets eliminate many foods that areimportant sources of energy, fiber, vita-mins,andmineralsandareimportantindietary palatability (22).Meal replacements (liquid or solidprepackaged) provide a defined amountofenergy,oftenasaformulaproduct.Useof meal replacements once or twice dailyto replace a usual meal can result in sig-nificant weight loss. Meal replacementsareanimportantpartoftheLookAHEADweight loss intervention (17). However,meal replacement therapy must be con-tinued indefinitely if weight loss is to bemaintained. Very-low-calorie diets provide
800calories daily and produce substantialweight loss and rapid improvements inglycemia and lipemia in individuals withtype 2 diabetes. When very-low-caloriediets are stopped and self-selected mealsare reintroduced, weight regain is com-mon. Thus, very-low-calorie diets appearto have limited utility in the treatment of type 2 diabetes and should only be con-sidered in conjunction with a structuredweight loss program.Theavailabledatasuggestthatweightloss medications may be useful in thetreatment of overweight individuals withand at risk for type 2 diabetes and canhelp achieve a 5–10% weight loss whencombined with lifestyle change (14). Ac-cording to their labels, these medicationsshould only be used in people with dia-betes who have BMI
27.0 kg/m
2
.Gastric reduction surgery can be aneffective weight loss treatment for obesityand may be considered in people with di-abeteswhohaveBMI
35kg/m
2
.Ameta-analysis of studies of bariatric surgeryreported that 77% of individuals withtype 2 diabetes had complete resolutionof diabetes (normalization of blood glu-coselevelsintheabsenceofmedications),and diabetes was resolved or improved in86% (23). In the Swedish Obese Subjectsstudy, a 10-year follow-up of individualsundergoingbariatricsurgery,36%ofsub- jects with diabetes had resolution of dia-betes compared with 13% of matchedcontrol subjects (24). All cardiovascularrisk factors except hypercholesterolemiaimproved in the surgical patients.
NUTRITIONRECOMMENDATIONS ANDINTERVENTIONS FOR THEPREVENTION OF DIABETES(PRIMARY PREVENTION)
Recommendations
●
Among individuals at high risk for de-veloping type 2 diabetes, structuredprograms that emphasize lifestylechanges that include moderate weightloss (7% body weight) and regularphysical activity (150 min/week), withdietary strategies including reducedcalories and reduced intake of dietaryfat, can reduce the risk for developingdiabetes and are therefore recom-mended. (A)
●
Individuals at high risk for type 2 dia-betes should be encouraged to achievethe U.S. Department of Agriculture(USDA)recommendationfordietaryfi-ber (14 g fiber/1,000 kcal) and foodscontaining whole grains (one-half of grain intake). (B)
●
There isnot sufficient, consistent infor-mation to conclude that low–glycemicload diets reduce the risk for diabetes.Nevertheless, low–glycemic indexfoods that are rich in fiber and otherimportant nutrients are to be encour-aged. (E)
●
Observational studies report that mod-eratealcoholintakemayreducetheriskfor diabetes, but the data do not sup-port recommending alcohol consump-tion to individuals at risk of diabetes.(B)
●
No nutrition recommendation can bemade for preventing type 1 diabetes.(E)
●
Although there are insufficient data atpresent to warrant any specific recom-mendationsforpreventionoftype2di-abetesinyouth,itisreasonabletoapplyapproaches demonstrated to be effec-tive in adults, as long as nutritionalneeds for normal growth and develop-ment are maintained. (E)The importance of preventing type2diabetesishighlightedbythesubstan-tial worldwide increase in the preva-lence of diabetes in recent years.Genetic susceptibility appears to play apowerful role in the occurrence of type2 diabetes. However, given that popu-lation gene pools shift very slowly overtime, the current epidemic of diabeteslikely reflects changes in lifestyle lead-ing to diabetes. Lifestyle changes char-acterized by increased energy intakeand decreased physical activity appearto have together promoted overweightand obesity, which are strong risk fac-tors for diabetes.Several studies have demonstratedthe potential for moderate, sustainedweight loss to substantially reduce therisk for type 2 diabetes, regardless of whether weight loss was achieved by life-style changes alone or with adjunctivetherapies such as medication or bariatric-surgery (see
ENERGY BALANCE
section) (1).Moreover, both moderate-intensity andvigorous exercise can improve insulin
Position Statement
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