Diabetes Type 1 and 2 · Lemon CC, Lacey K, Lohse B, Hubacher DO, Klawitter B, Palta M. Outcomes monitoring of health, behavior, and quality of life after nutrition intervention in

Diabetes Type 1 and 2Diabetes (DM) Guideline (2008)

Diabetes Type 1 and 2

DM: Major Recommendations (2008)Diabetes Type 1 and 2 Evidence-Based Nutrition Practice Guideline for Adults

Below, you will find a list of Diabetes Mellitus (DM) Type 1 and 2 recommendations, organized by topic. Also view the Executive Summary of Recommendations or print the guideline in PDF format.

Diabetes Mellitus (DM) Major Recommendations

DM: Medical Nutrition Therapy and Diabetes DM: Assessment and Diabetes DM: Assessment of Glycemic ControlDM: Assess Importance of Weight ManagementDM: Intervention Options DM: MacronutrientsDM: Carbohydrate and DiabetesDM: Sucrose and DiabetesDM: Non-Nutritive Sweeteners and Diabetes DM: Glycemic Index and DiabetesDM: Fiber and DiabetesDM: Protein and DiabetesDM: Glucose Monitoring and Diabetes DM: Prevention and Treatment of CVD and DiabetesDM: Weight Management and Diabetes DM: Physical Activity and DiabetesDM: Coordination of Care and Diabetes DM: Monitor and Evaluate and Diabetes

The recommendations listed below were originally developed for other ADA evidence-based guidelines, but have been integratedinto the Diabetes evidence-based nutrition practice guideline.

Adult Weight Management (AWM)

AWM: Classification of Overweight and ObesityAWM: Comprehensive Weight Management ProgramAWM: Determining Energy NeedsAWM: Eating Frequency and Patterns AWM: Meal ReplacementsAWM: Use of Weight Loss MedicationsAWM: Multiple Behavior Therapy StrategiesAWM: Weight Management Nutrition EducationAWM: Optimal Length of Weight Management TherapyAWM: Portion ControlAWM: Realistic Weight Goals

Disorders of Lipid Metabolism (DLM)

DLM: Alcohol IntakeDLM: Antioxidants (Vitamin E, Vitamin C and Beta-Carotene)DLM: Homocysteine, Folate, Vitamin B6 and B12DLM: Major Dietary Fat ComponentsDLM: Omega-3 Food SourcesDLM: Omega-3 SupplementsDLM: Plant Stanols and SterolsDLM: Referral to a Registered Dietitian for MNT for Disorders of Lipid MetabolismDLM: Soy ProteinDLM: Trans-Fatty Acid IntakeDLM: Elevated Triglycerides and Macronutrients DLM: Elevated Triglycerides and EPA/DHA Supplements

Hypertension (HTN)

HTN: Blood Pressure Measurement in Monitoring and EvaluationHTN: Comprehensive Program for Blood Pressure ManagementHTN: Blood Pressure Treatment Goal for Individuals with Diabetes or Renal DiseaseHTN: Dietary Approaches to Stop Hypertension (DASH) Dietary PatternHTN: Sodium IntakeHTN: Caffeine IntakeHTN: Food/Nutrient and Medication Interaction Assessment


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Recommendations Summary

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DM: Medical Nutrition Therapy 2008

Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels(Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use thehyperlinks in the Supporting Evidence Section below.

Recommendation(s) DM: MNT and Number/Length of Initial Series of Encounters

Medical nutrition therapy (MNT) provided by a registered dietitian (RD) is recommended for individuals with type 1 andtype 2 diabetes. An initial series of three to four encounters each lasting from 45 to 90 minutes is recommended. Thisseries, beginning at diagnosis of diabetes or at first referral to an RD for MNT for diabetes, should be completed withinthree to six months. The RD should determine if additional MNT encounters are needed after the initial series based onthe nutrition assessment of learning needs and progress towards desired outcomes. Studies based on a range in thenumber (1-5 individual sessions or a series of 6-12 group sessions) and length (45-90 minutes) report sustained positiveoutcomes at one year and longer. Studies implementing a variety of nutrition interventions report a reduction in A1Clevels, and some studies also report improved lipid profiles, improved weight management, adjustments in medications,and reduction in the risk for onset and progression of comorbidities.

Rating: StrongImperative

DM: MNT Long-Term Follow-up Encounters

At least one follow-up encounter is recommended annually to reinforce lifestyle changes and to evaluate and monitoroutcomes that impact the need for changes in MNT or medication. The RD should determine if additional MNT encountersare needed. Studies involving regular lifestyle intervention sessions (up to 1 per month) report sustained positiveoutcomes at one year and longer.


Risks/Harms of Implementing This Recommendation

None.

Conditions of Application

None.

Potential Costs Associated with Application

Although costs of MNT sessions and reimbursement vary, medical nutrition therapy sessions are essentialfor improved outcomes.

Recommendation Narrative

MNT has its greatest impact at diagnosis of diabetes (Monk et al, 1995; Delahanty et al, 1998).Eight studies (Franz et al, 1995; DAFNE Study Group, 2002; Graber et al, 2002; Miller et al, 2002;Goldhaber-Fiebert et al, 2003; Wilson et al, 2003; Lemon et al, 2004; Gaetke et al, 2006), evaluating theeffectiveness of diabetes MNT at three to six months, reported reductions in A1C, ranging from 0.25% to2.9%, depending on the type and duration of diabetes. Individual sessions ranging from one to five or aseries of 10 to 12 group sessions were employed.A variety of nutrition therapy interventions, such as a reduced energy and fat intake, carbohydratecounting, simplified meal plans, healthy food choices, individualized meal planning strategies, exchangelists, insulin-to-carbohydrate ratios and behavioral strategies were implemented.The number of initial and follow-up sessions varies in all the studies.Studies reporting on effectiveness of MNT from six to twelve months (Lemon et al, 2004; DAFNE StudyGroup, 2002; Franz et al, 1995; Wolf et al, 2004; Banister et al, 2004; Chima et al, 2005; Bray et al,2005) report a variety in the number and type of MNT sessions that lead to improved outcomes.Therefore, the RD needs to determine what is appropriate for individual clients.Seven studies (DCCT, 1993; Laitinen et al, 1993; Maislos et al, 2002; Banister et al, 2004; Wolf et al,2004; Bray et al, 2005; Chima et al, 2005) report sustained improvements in A1C at 12 months andlonger. All involved regular sessions with an RD, ranging from monthly to three sessions per year.Seven studies (DCCT, 1993; Franz et al, 1995; Goldhaber-Fieber et al, 2003; Banister et al, 2004; Lemonet al, 2004; Wolf et al, 2004; Gaetke et al, 2006) report improvements in other outcomes, such asimproved lipid profiles, weight management, decreased need for medications and reduced risk for onsetand progression of comorbidities.

Recommendation Strength Rationale

Conclusion statement was Grade I

Minority Opinions

Consensus reached.

Supporting Evidence


The recommendations were created from the evidence analysis on the following questions. To see detail of the evidenceanalysis, click the blue hyperlinks below (recommendations rated consensus will not have supporting evidence linked).

How effective is MNT provided by Registered Dietitians in the management of persons with type 1 and type 2 diabetes?

References Ash S, Reeves MM, Yeo S, Morrison G, Carey D, Capra S. Effect of intensive dietetic interventions on weight andglycaemic control in overweight men with Type II diabetes: a randomised trial. International Journal of Obesity.2003; 27:797-802.

Banister NA, Jastrow ST, Hodges V, Loop R, Gillham MB. Diabetes self-management training program in acommunity clinic improves patient outcomes at modest cost. J Am Diet Assoc 2004;104(5):807-10.

Bray P, Thompson D, Wynn JD, Cummings DM, Whetstone L. Confronting Disparities in Diabetes Care: Theclinical effectiveness of redesigning care management for minority patients in rural primary care practices. J RuralHealth 2005; 21(4):317-21.

Chima CS, Farmer-Dziak N, Cardwell P, Snow S. Use of technology to track outcomes in a diabetesself-management program. J Am Diet Assoc 2005; 105(12):1933-8.

DAFNE Study Group. Training in flexible, intensive insulin management to enable dietary freedom in people withtype 1 diabetes: dose adjustment for normal eating (DAFNE) randomised controlled trial. Brit Med J. 2002;325:746-751.

The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on thedevelopment and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med1993; 329:977-986.

Franz MJ, Monk A, Barry B, McClain K, Weaver T, Cooper N, Upham P, Bergenstal R, Mazze RS. Effectiveness ofmedical nutrition therapy provided by dietitians in the management of non-insulin-dependent diabetes mellitus: a randomized controlled clinical trial. J Am Diet Assoc 1995;95:1009-1017.

Gaetke LM, Stuart MA, Truszczynska H. A single nutrition counseling session with a registered dietitian improvesshort-term clinical outcomes for rural Kentucky patients with chronic disease. J Am Diet Assoc2006;106(1):109-112.

Goldhaber-Fiebert JD, Goldhaber-Fiebert SN, Tristan ML, Nathan DM. Randomized controlled community-basednutrition and exercise intervention improves glycemia and cardiovascular risk factors in type 2 diabetic patients inrural Costa Rica. Diabetes Care 2003; 26:24-29.

Graber AL, Elasy TA, Quinn D, Wolff K, Brown A. Improving glycemic control in adults with diabetes mellitus:shared responsibility in primary care practices. South Med J 2002; 95(7):684-90.

Laitinen JH, Ahola IE, Sarkkinen ES, Winberg RL, Harmaakorpi-Livonen PA, Uusitupa MI. Impact of intensifieddietary therapy on energy and nutrient intakes and fatty acid composition of serum lipids in patients with recentlydiagnosed non-insulin-dependent diabetes mellitus. J Am Diet Assoc 1993;93(3):276-283.

Lemon CC, Lacey K, Lohse B, Hubacher DO, Klawitter B, Palta M. Outcomes monitoring of health, behavior, andquality of life after nutrition intervention in adults with type 2 diabetes. J Am Diet Assoc 2004; 104(12):1085-15.

Maislos M, Weisman D, Sherf M. Western Negev Mobile Diabetes Care Program: a model for interdisciplinarydiabetes care in a semi-rural setting. Acta Diabetol 2002; 39(1):49-53.

Miller CK, Edwards L, Kissling G, Sanville L. Nutrition education improves metabolic outcomes among older adultswith diabetes mellitus:results from a randomized controlled trial. Prev Med 2002;34(2):252-9.

Wilson C, Brown T, Acton K, Gilliland A. Effects of clinical nutrition education and educator discipline on glycemiccontrol outcomes in the Indian Health Service. Diabetes Care 2003; 26(6):2500-04.

Wolf AM, Conaway MR, Crowther JQ, Hazen KY, Nadler JL, Oneida B, Bovbjerg VE. Translating LifestyleIntervention to Practice in Obese Patients with Type 2 Diabetes: Improving Control with Activity and Nutrition(ICAN) study. Diabetes Care, 2004; 27 (7): 1,570-1,576.

Delahanty LM, et al. Clinical Significance of medical nutrition therapy in achieving diabetes outcomes and theimportance of the process. J Am Diet Assoc. 1998; 98: 28-30.

Monk A, Barry B, McClain K, Weaver T, Cooper N, Franz MJ. Practice guidelines for medical nutrition therapyprovided by dietitians for persons with non-insulin-dependent diabetes mellitus. J Am Diet Assoc1995;95:999-1006.


Quick Links

Recommendations SummaryDM: Assessment and Diabetes 2008



Recommendation(s) DM: Nutrition Assessment

The RD should assess food intake (focusing on carbohydrate), medication, metabolic control (glycemia, lipids, and bloodpressure), anthropometric measurements and physical activity to serve as the basis for implementation of the nutritionprescription, goals and intervention. Individuals who have diabetes should receive MNT tailored by the RD.



None.


None.




MNT has its greatest impact at diagnosis of diabetes (Monk et al, 1995; Delahanty et al, 1998).Eight studies (Franz et al, 1995; DAFNE Study Group, 2002; Graber et al, 2002; Miller et al, 2002;Goldhaber-Fiebert et al, 2003; Wilson et al, 2003; Lemon et al, 2004; Gaetke et al, 2006), evaluating theeffectiveness of diabetes MNT at three to six months, reported reductions in A1C, ranging from 0.25% to2.9%, depending on the type and duration of diabetes. Individual sessions ranging from one to five or aseries of 10 to 12 group sessions were employed.A variety of nutrition therapy interventions, such as a reduced energy and fat intake, carbohydratecounting, simplified meal plans, healthy food choices, individualized meal planning strategies, exchangelists, insulin-to-carbohydrate ratios and behavioral strategies were implemented.The number of initial and follow-up sessions varies in all the studies.Studies reporting on effectiveness of MNT from six to twelve months (Lemon et al, 2004; DAFNE StudyGroup, 2002; Franz et al, 1995; Wolf et al, 2004; Banister et al, 2004; Chima et al, 2005; Bray et al,2005) report a variety in the number and type of MNT sessions that lead to improved outcomes.Therefore, the RD needs to determine what is appropriate for individual clients.Seven studies (DCCT, 1993; Laitinen et al, 1993; Maislos et al, 2002; Banister et al, 2004; Wolf et al,2004; Bray et al, 2005; Chima et al, 2005) report sustained improvements in A1C at 12 months andlonger. All involved regular sessions with an RD, ranging from monthly to three sessions per year.Seven studies (DCCT, 1993; Franz et al, 1995; Goldhaber-Fieber et al, 2003; Banister et al, 2004; Lemonet al, 2004; Wolf et al, 2004; Gaetke et al, 2006) report improvements in other outcomes, such asimproved lipid profiles, weight management, decreased need for medications and reduced risk for onsetand progression of comorbidities.American Diabetes Association Recommendation: Individuals who have pre-diabetes or diabetes shouldreceive individualized MNT; such therapy is best provided by a registered dietitian familiar with thecomponents of diabetes MNT (Grade B).


Conclusion Statement given Grade I

Minority Opinions

Consensus reached.

Supporting Evidence The recommendations were created from the evidence analysis on the following questions. To see detail of the evidenceanalysis, click the blue hyperlinks below (recommendations rated consensus will not have supporting evidence linked).





















References not graded in Academy of Nutrition and Dietetics Evidence Analysis Process

American Diabetes Association. Nutrition recommendations and interventions for diabetes: a position statementof the American Diabetes Association. Diabetes Care 2007;30 Suppl 1:S48-65.

Wylie-Rosett J, Albright AA, Apovian C, Clark NG, Delahanty L, Franz MJ, Hoogwerf B, Kulkarni K, Lichtenstein AH,Mayer-Davis E, Mooradian AD, Wheeler M. 2006-2007 American Diabetes Association NutritionRecommendations: issues for practice translation. J Am Diet Assoc 2007;107(8):1296-304.


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Recommendations SummaryDM: Assessment of Glycemic Control 2008


Recommendation(s) DM: Assessment of Glycemic Control

The RD should assess glycemic control and focus medical nutrition therapy to achieve and maintain blood glucose levelsin the target range (target glucose levels noted in the American Diabetes Association Standards of Medical Care inDiabetes). Studies evaluating the effectiveness of diabetes MNT at three to six months reported reductions in A1C rangingfrom 0.25% to 2.9%.


http://care.diabetesjournals.org/cgi/content/full/31/Supplement_1/S12

http://care.diabetesjournals.org/cgi/content/full/31/Supplement_1/S12



None.


None.




MNT has its greatest impact at diagnosis of diabetes (Monk et al, 1995; Delahanty et al, 1998).Eight studies (Franz et al, 1995; DAFNE Study Group, 2002; Graber et al, 2002; Miller et al, 2002;Goldhaber-Fiebert et al, 2003; Wilson et al, 2003; Lemon et al, 2004; Gaetke et al, 2006), evaluating theeffectiveness of diabetes MNT at three to six months, reported reductions in A1C, ranging from 0.25% to2.9%, depending on the type and duration of diabetes. Individual sessions ranging from one to five or aseries of 10 to 12 group sessions were employed.A variety of nutrition therapy interventions, such as a reduced energy and fat intake, carbohydratecounting, simplified meal plans, healthy food choices, individualized meal planning strategies, exchangelists, insulin-to-carbohydrate ratios and behavioral strategies were implemented.The number of initial and follow-up sessions varies in all the studies.Studies reporting on effectiveness of MNT from six to twelve months (Lemon et al, 2004; DAFNE StudyGroup, 2002; Franz et al, 1995; Wolf et al, 2004; Banister et al, 2004; Chima et al, 2005; Bray et al,2005) report a variety in the number and type of MNT sessions that lead to improved outcomes.Therefore, the RD needs to determine what is appropriate for individual clients.Seven studies (DCCT, 1993; Laitinen et al, 1993; Maislos et al, 2002; Banister et al, 2004; Wolf et al,2004; Bray et al, 2005; Chima et al, 2005) report sustained improvements in A1C at 12 months andlonger. All involved regular sessions with an RD, ranging from monthly to three sessions per year.Seven studies (DCCT, 1993; Franz et al, 1995; Goldhaber-Fieber et al, 2003; Banister et al, 2004; Lemonet al, 2004; Wolf et al, 2004; Gaetke et al, 2006) report improvements in other outcomes, such asimproved lipid profiles, weight management, decreased need for medications and reduced risk for onsetand progression of comorbidities.American Diabetes Association Recommendation: Target A1C is as close to normal as possible withoutsignificant hypoglycemia (Grade B).


Conclusion Statement was Grade I

Minority Opinions

Consensus reached.


























Quick Links

Recommendations SummaryDM: Assess Relative Importance of Weight Management 2008


Recommendation(s) DM: Assess Relative Importance of Weight Management

The RD should assess the relative importance of weight management for persons with diabetes who are overweight or obese. While modest weight loss has been shown to improve insulin resistance in overweight and obese insulin-resistantindividuals, research on sustained weight loss interventions lasting 1 year or longer reported inconsistent effects on A1C.

Rating: StrongConditional


None.



Recommendations apply to persons with diabetes who are overweight or obese.


Although costs of MNT sessions and reimbursement vary, medical nutrition therapy sessions are essential forimproved outcomes.


In randomized clinical trials, approximately half report improvement in A1C values with weight loss;whereas, approximately half report no improvement in A1C values despite fairly similar weight losses. Eleven studies with more than 1 diet arm (Hollander et al, 1998; Manning et al, 1998; Hanefeld et al,2002; Miles et al, 2002; Kelley et al, 2003; Redmon et al, 2003; Brinkworth et al, 2004; Metz et al,2004; Wolf et al, 2004; Li et al, 2005; Berne et al, 2005; Redmon et al, 2005) reported weight loss andA1C values at 12 months. Six studies in diet arms reported no improvement in A1C (Hollander et al, 1998; Manning et al, 1998;Redmon et al, 2003; Brinkworth et al, 2004; Wolf et al, 2004; Li et al, 2005; Redmon et al, 2005)despite weight loss (range: -0.8 to -4.4 kg) in all but one study which reported no weight loss (Manninget al, 1998). Five studies in diet arms reported improvement in A1C ranging from -0.2% to -0.6% (Hanefeld et al,2002; Miles et al, 2002; Kelley et al, 2003; Mertz et al, 2004; Berne et al, 2005) with fairly similar weightlosses (range: -1.3 to -5.1 kg).Studies using weight loss medications (orlistat and lifestyle, sibutramine) report consistent improvementin A1C. Six studies with an orlistat arm (Hollander et al, 1998; Hanefeld et al, 2002; Miles et al, 2002;Kelley et al, 2003; Derosa et al, 2004; Berne et al, 2005) reported improvements in A1C values (range:-0.3% to -1.1%) with orlistat and lifestyle intervention with weight loss (range: -3.9 to -6.2 kg). Four studies (McNulty et al, 2003; Redmon et al, 2003; Derosa et al, 2004; Sanchez-Reyes et al, 2004;Redmon et al, 2005) reported improvements in A1C values (range: -0.3% to -6.0%) with sibutraminewith weight loss (range: -4.1 to -8.0 kg).Ten studies reported significant improvements in at least one lipid value, generally in triglycerides and HDLcholesterol from weight loss either by diet alone or with weight loss medications (Hollander et al, 1998;Hanefeld et al, 2002; Miles et al, 2002; Paisey et al, 2002; Ash et al, 2003; Kelley et al, 2003; McNulty etal, 2003; Metz et al, 2004; Berne et al, 2005; Li et al, 2005). Six studies reported improvement in blood pressure with weight loss (Miles et al, 2002; Redmon et al,2003; Brinkworth et al, 2004; Derosa et al, 2004; Metz et al, 2004; Li et al, 2005; Redmon et al, 2005);however, one study using sibutramine reported increases in blood pressure (McNulty et al, 2003) and onestudy using sibutramine reported no change in blood pressure (Derosa et al, 2004). American Diabetes Association Recommendation: In overweight and obese insulin-resistant individuals,modest weight loss has been shown to improve insulin resistance. Thus, weight loss is recommended forall such individuals who have or are at risk for diabetes (Grade A).


Conclusion Statement given Grade II

Minority Opinions

Consensus reached.


What is the long-term effect (1 year or greater) of weight management on metabolic outcomes in persons with type 1and type 2 diabetes?


Berne C, for the Orlistat Swedish Type 2 Diabetes Study Group. A randomized study of orlistat in combinationwith a weight management programme in obese patients with Type 2 diabetes treated with metformin. DiabeticMedicine 2005;22: 612-618.

Brinkworth GD, Noakes M, Parker B, Foster P, Clifton PM. Long-term effects of advice to consume a high-protein,low-fat diet, rather than a conventional weight-loss diet, in obese adults with Type 2 diabetes: one-year follow-upof a randomized trial. Diabetologia 2004; 47:1677-1686.

Brown SA, Upchurch S, Anding R, Winter M, Ramirez G. Promoting weight loss in type 2 diabetes. Diabetes Care.1996;19(6):613-624.

Derosa G, Cicero AF, Murdolo G, Ciccarelli L, Fogari R. Comparison of metabolic effects of orlistat and sibutraminetreatment in Type 2 diabetic obese patients. Diabetes Nutr Metab 2004;17:222-229.

Hanefeld M, Sachse G. The effects of orlistat on body weight and glycaemic control in overweight patients withtype 2 diabetes: a randomized, placebo-controlled trial. Diabetes, Obesity and Metabolism 2002; 4:415-423.

Hollander PA, Elbein SC, Hirsch IB, Kelley D, McGill J, Taylor T, Weiss SR, Crockett SE, Kaplan RA, Comstock J,Lucas CP, Lodewick PA, Canovatchel W, Chung J, Hauptman J. Role of orlistat in the treatment of obese patientswith type 2 diabetes. Diabetes Care. 1998;21:1288-1294.


Kelley DE, Bray GA, Pi-Sunyer FX, Klein S, Hill J, Miles J, Hollander P. Clinical efficacy of orlistat therapy inoverweight and obese patients with insulin-treated type 2 diabetes: a 1-year randomized controlled trial .Diabetes Care 2002;25:1033-1041.

Li Z, Hong K, Saltsman P, DeShields S, Bellman M, Thames G, Liu Y, Wang H-J, Elashoff R, Heber D. Long-termefficacy of soy-based meal replacements vs an individualized diet plan in obese type II DM patients: relativeeffects on weight loss, metabolic parameters, and C-reactive protein. Eur J Clin Nutr 2005;59:411-418

Manning RM, Jung RT, Leese GP, Newton RW. The Comparison of Four Weight Reduction Strategies Aimed atOverweight Patients with Diabetes Mellitus: Four-year Follow-up. Diabetic Medicine 1998;15:497-502.

Mayer-Davis EJ, D'Antonio AM, Smith SM, Kirkner G, Martin SL, Parra-Medina D, Schultz R. Pounds off withEmpowerment (POWER): a clinical trial of weight management strategies for black and white adults with diabeteswho live in medically underserved rural communities. Am J Public Health. 2004;94:1736-1742.

McNulty SJ, Ur E, Williams G; for the Multicenter Sibutramine Study Group. A randomized trial of sibutramine inthe management of obese type 2 diabetic patients treated with metformin. Diabetes Care. 2003; 125-131.

Metz JA, Stern JS, Kris-Etherton P, Reusser ME, Morris CD, Hatton DC, Oparil S, Haynes RB, Resnick LM,Pi-Sunyer FX, Clark S, Chester L, McMahon M, Snyder GW, McCarron DA. A randomized trial of improved weightloss with a prepared meal plan in overweight and obese patients: impact on cardiovascular risk reduction. ArchIntern Med. 2000; 160: 2,150-2,158.

Miles JM, Leiter L, Hollander P, Wadden T, Anderson JW, Doyle M, Foreyt J, Aronne L and Klein S. Effect of orlistatin overweight and obese patients with type 2 diabetes treated with metformin. Diabetes Care2002;25(7):1123-1128.

Norris SL, Zhang X, Avenell A, Gregg E, Bowman B, Serdula M, Brown TJ, Schmid CH and Lau J. Long-termeffectiveness of lifestyle and behavioral weight loss interventions in adults with type 2 diabetes: a meta-analysis.Am J Med 2004 Nov 15;117(10):762-74.

Paisey RB, Frost J, Harvey P, Paisey A, Bower L, Paisey RM, Taylor P, Belka I. Five-year results of a prospectivevery low calorie diet or conventional weight loss programme in type 2 diabetes. J Hum Nutr Diet2002;15(2):121-7.

Redmon JB, Raatz SK, Reck KP, Swanson JE, Kwong CA, Fan Q, Thomas W and Bantle JP. One-year outcome of acombination of weight loss therapies for subjects with type 2 diabetes: a randomized trial. Diabetes Care2003;26(9):2505-2511.

Redmon JB, Reck KP, Raatz SK, Swanson JE, Kwong CA, Ji H, Thomas W, Bantle JP. Two-year outcome of acombination of weight loss therapies for Type 2 diabetes. Diabetes Care 2005;28:1311-1315.

Sanchez-Reyes L, Fanghanel G, Yamamoto J, Martinez-Rivas L, Campos-Franco E, Berber A. Use of sibutramine inoverweight adult Hispanic patients with type 2 diabetes mellitus: A 12-month, randomized, double-blindplacebo-controlled clinical trial. Clinical Therapeutics. 2004; 26(9):1,427-1,435.

Vettor R, Serra R, Fabris R, Pagano C and Federspil G. Effect of sibutramine on weight management andmetabolic control in type 2 diabetes: A meta-analysis of clinical studies. Diabetes Care. 2005; 28(4): 942-949.

Wing RR, Koeske R, Epstein LH, Nowalk MP, Gooding W, Becker D. Long-term effects of modest weight-loss intype II diabetic patients. Arch Intern Med. 1987;147:1749-1753.






Quick Links

Recommendations SummaryDM: Intervention Options 2008


Recommendation(s) DM: Intervention Options


The RD should implement MNT selecting from a variety of interventions (reduced energy and fat intake, carbohydratecounting, simplified meal plans, healthy food choices, individualized meal planning strategies, exchange lists,insulin-to-carbohydrate ratios, physical activity and behavioral strategies). Nutrition education and counseling should besensitive to the personal needs, willingness to change, and ability to make changes of the individual with diabetes. Studies reporting on effectiveness of MNT report a variety in the number and type of MNT sessions that lead to improvedoutcomes.



None.


None.




MNT has its greatest impact at diagnosis of diabetes (Monk et al, 1995; Delahanty et al, 1998).Eight studies (Franz et al, 1995; DAFNE Study Group, 2002; Graber et al, 2002; Miller et al, 2002;Goldhaber-Fiebert et al, 2003; Wilson et al, 2003; Lemon et al, 2004; Gaetke et al, 2006), evaluating theeffectiveness of diabetes MNT at three to six months, reported reductions in A1C, ranging from 0.25% to2.9%, depending on the type and duration of diabetes. Individual sessions ranging from one to five or aseries of 10 to 12 group sessions were employed.A variety of nutrition therapy interventions, such as a reduced energy and fat intake, carbohydratecounting, simplified meal plans, healthy food choices, individualized meal planning strategies, exchangelists, insulin-to-carbohydrate ratios and behavioral strategies were implemented.The number of initial and follow-up sessions varies in all the studies.Studies reporting on effectiveness of MNT from six to twelve months (Lemon et al, 2004; DAFNE StudyGroup, 2002; Franz et al, 1995; Wolf et al, 2004; Banister et al, 2004; Chima et al, 2005; Bray et al,2005) report a variety in the number and type of MNT sessions that lead to improved outcomes.Therefore, the RD needs to determine what is appropriate for individual clients.Seven studies (DCCT, 1993; Laitinen et al, 1993; Maislos et al, 2002; Banister et al, 2004; Wolf et al,2004; Bray et al, 2005; Chima et al, 2005) report sustained improvements in A1C at 12 months andlonger. All involved regular sessions with an RD, ranging from monthly to three sessions per year.Seven studies (DCCT, 1993; Franz et al, 1995; Goldhaber-Fieber et al, 2003; Banister et al, 2004; Lemonet al, 2004; Wolf et al, 2004; Gaetke et al, 2006) report improvements in other outcomes, such asimproved lipid profiles, weight management, decreased need for medications and reduced risk for onsetand progression of comorbidities.American Diabetes Association Recommendation: Nutrition counseling should be sensitive to the personalneeds, willingness to change, and ability to make changes of the individual with pre-diabetes or diabetes(Grade E).


Conclusion Statement was given Grade I

Minority Opinions

Consensus reached.







DAFNE Study Group. Training in flexible, intensive insulin management to enable dietary freedom in people with


type 1 diabetes: dose adjustment for normal eating (DAFNE) randomised controlled trial. Brit Med J. 2002;325:746-751.


















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Recommendations SummaryDM: Macronutrients 2008


Recommendation(s) DM: Macronutrient Percentages

The RD should encourage consumption of macronutrients based on the Dietary Reference Intakes (DRI) for healthyadults. Research does not support any ideal percentage of energy from macronutrients for persons with diabetes.




Although total carbohydrate content of meals and snacks is the first priority, macronutrient content andtotal energy intake cannot be ignored as excessive energy intake may lead to weight gain, even ifglycemic control is maintained. Diets too low in carbohydrate eliminate many foods that are important sources of vitamins, minerals, fiberand energy. Diets too low in protein and energy can lead to hypoalbuminemia, and both intake and albumin levelsneed to be monitored in persons with diabetic nephropathy who are restricting protein intake and mayhave a diminished appetite.


In persons with diabetic nephropathy, hypoalbuminemia and weight must be monitored.




Two studies in subjects with Type I diabetes based the adjustment of mealtime insulin to match plannedcarbohydrate intake (DCCT, 1993; DAFNE Study Group, 2002) and three studies based on day-to-dayconsistency in carbohydrate intake resulted in improved glycemic control (Wolever et al, 1999; Boden etal, 2005; Nielsen, Jonsson, and Nilsson, 2005). Of four studies evaluating differing percentages of carbohydrate, the evidence was inconclusive (Garg etal, 1994; Komiyama et al, 2002; Gerhard et al, 2004; Nielsen, Jonsson, and Ivarsson, 2005).The amount of protein consumed at meals has minimal influence onglycemic response, on lipids, on hormones and metabolites, and shows no long-term effect on insulinrequirements.Two single meal studies (Nordt et al, 1991; Gannon et al, 2001) report an acute insulin response toingestion of protein. However, three studies (Luscombe et al, 2002; Parker et al, 2002; Gannon et al, 2003) based on higherprotein diets (30% of energy from protein) lasting five to twelve weeks showed no significant difference inlonger-term insulin response; one study (Gannon et al, 2003) showed a significant decrease in A1C. As the percentage of energy from protein is increased and the percentage of energy from fat remainsconstant, the percentage of energy from carbohydrate is decreased, and therefore it is difficult todetermine whether higher protein intakes or lower carbohydrate intakes result in significant effects onmetabolic outcomes. American Diabetes Association Recommendation: A dietary pattern that includes carbohydrate from fruits,vegetables, whole grains, legumes, and low-fat milk is encouraged for good health (Grade B).American Diabetes Association Recommendation: For individuals with diabetes and normal renal function,there is insufficient evidence to suggest that usual protein intake (15-20% of energy) should be modified(Grade E).


Conclusion Statement for Carbohydrate was given Grade IConclusion Statement for Protein was given Grade II

Minority Opinions

Consensus reached.


What is the relationship between carbohydrate intake and metabolic outcomes in persons with type 1 and type 2 diabetes?

What is the relationship between protein intake and metabolic outcomes in persons with type 1 and type 2 diabetes?

References Boden G, Sargrad K, Homko C, Mozzoli M, Stein TP. Effect of a low-carbohydrate diet on appetite, blood glucoselevels, and insulin resistance in obese patients with type 2 diabetes. Ann Intern Med 2005; 142:403-411.



Garg A, Bantle JP, Henry RR, Coulston AM, Griver KA, Raatz SK, Brinkley L, Chen Y-D I, Grundy SM, Huet BA,Reaven GM. Effects of varying carbohydrate content of diet in patients with non-insulin-dependent diabetesmellitus. JAMA. 1994;271:1421-1428.

Gerhard GT, Ahmann A, Meeuws K, McMurry MP, Duell PB, Connor WE. Effects of a low-fat diet compared withthose of a high-monounsaturated fat diet on body weight, plasma lipids and lipoprotiens, and glycemic control intype 2 diabetes. Am J Clin Nutr. 2004; 80(3): 668-673.


Komiyama N, Kaneko T, Sato A, Sato W, Asami K, Onaya T, Tawata M. The effect of high carbohydrate diet onglucose tolerance in patients with type 2 diabetes mellitus. Diabetes Research and Clinical Practice 2002;57:163-170.

Nielsen JV, Jonsson E, Ivarsson A. A low-carbohydrate diet in type 1 diabetes: clinical experience--a briefreport. Upsala J Med Sci 2005;110:267-273.

Nielsen JV, Jonsson E, Nilsson AK. Lasting improvement of hyperglycemia and bodyweight: low-carbohydratediet in type 2 diabetes. A brief report. Upsala J Med Sci 2005; 109:179-184.

Wolever TMS, Hamad S, Chiasson JL, Josse RG, Leiter LA, Rodger NW, Ross SA, Ryan EA. Day-to-day consistencyin amount and source of carbohydrate intake associated with improved glucose control in type 1 diabetes. J AmerColl Nutr. 1999;18:242-247.

Gannon MC, Nuttall JA, Damberg G, Gupta V, Nuttall FQ. Effect of protein ingestion on the glucose appearancerate in people with type 2 diabetes. J Clin Endocrin Metab. 2001;86:1040-1047.

Gannon MC, Nuttall FQ, Saeed A, Jordan K, Hoover H. An increase in dietary protein improves the blood glucoseresponse in persons with type 2 diabetes. Am J Clin Nutr. 2003;78:734-741.

Luscombe ND, Clifton PM, Noakes M, Parker B, Wittert G. Effects of energy-restricted diets containing increasedprotein on weight loss, resting energy expenditure, and the thermic effect of feeding in type 2 diabetes. DiabetesCare 2002;25:652-657

Nordt TK, Besenthal I, Eggstein M, Jakober B. Influence of breakfasts with different nutrient contents on glucose,C peptide, insulin, glucagon, triglycerides, and GIP in non-insulin-dependent diabetics. Am J Clin Nutr.1991;53:155-160.

Nuttall FQ, Gannon MC, Saeed A, Jordan K, Hoover H. The metabolic response of subjects with type 2 diabetes toa high-protein, weight-maintenance diet. J Clin Endocrinol Metab. 2003;88:3577-3583.

Parker B, Noakes M, Luscombe N, Clifton P. Effect of a high-protein, high-monounsaturated fat weight loss diet onglycemic control and lipid levels in type 2 diabetes. Diabetes Care 2002;25:425-430.



Institute of Medicine: Dietary Reference Intakes: Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol,Protein, and Amino Acids. Washington, DC, National Academies Press, 2002.



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Recommendations SummaryDM: Carbohydrate 2008


Recommendation(s) DM: Carbohydrate Intake Consistency

In persons receiving either MNT alone, glucose-lowering medications or fixed insulin doses, meal and snack carbohydrateintake should be kept consistent on a day-to-day basis. Consistency in carbohydrate intake results in improved glycemiccontrol.


DM: Carbohydrate Intake and Insulin Dose Adjustment

In persons with type 1 or type 2 diabetes who adjust their mealtime insulin doses or who are on insulin pump therapy, insulin doses should be adjusted to match carbohydrate intake (insulin-to-carbohydrate ratio). This can be accomplishedby comprehensive nutrition education and counseling on interpretation of blood glucose patterns, nutrition-relatedmedication management and collaboration with the healthcare team. Adjusting insulin dose based on plannedcarbohydrate intake improves glycemic control and quality of life without any adverse effects.




Although total carbohydrate content of meals and snacks is the first priority, macronutrient content andtotal energy intake cannot be ignored as excessive energy intake may lead to weight gain, even ifglycemic control is maintained. Diets too low in carbohydrate eliminate many foods that are important sources of vitamins, minerals, fiberand energy.


The scope of practice of the RD and standards of professional performance defines the role of the RD inmedication adjustment.




Two studies in subjects with Type I diabetes based the adjustment of mealtime insulin to match plannedcarbohydrate intake (DCCT, 1993; DAFNE Study Group, 2002) and three studies based on day-to-dayconsistency in carbohydrate intake resulted in improved glycemic control (Wolever et al, 1999; Boden etal, 2005; Nielsen, Jonsson, and Nilsson, 2005). Of four studies evaluating differing percentages of carbohydrate, the evidence was inconclusive (Garg etal, 1994; Komiyama et al, 2002; Gerhard et al, 2004; Nielsen, Jonsson, and Ivarsson, 2005).



Minority Opinions

Consensus reached.


What is the relationship between carbohydrate intake and metabolic outcomes in persons with type 1 and type 2 diabetes?

References Boden G, Sargrad K, Homko C, Mozzoli M, Stein TP. Effect of a low-carbohydrate diet on appetite, blood glucoselevels, and insulin resistance in obese patients with type 2 diabetes. Ann Intern Med 2005; 142:403-411.



Garg A, Bantle JP, Henry RR, Coulston AM, Griver KA, Raatz SK, Brinkley L, Chen Y-D I, Grundy SM, Huet BA,Reaven GM. Effects of varying carbohydrate content of diet in patients with non-insulin-dependent diabetesmellitus. JAMA. 1994;271:1421-1428.


Komiyama N, Kaneko T, Sato A, Sato W, Asami K, Onaya T, Tawata M. The effect of high carbohydrate diet onglucose tolerance in patients with type 2 diabetes mellitus. Diabetes Research and Clinical Practice 2002;57:163-170.

Nielsen JV, Jonsson E, Ivarsson A. A low-carbohydrate diet in type 1 diabetes: clinical experience--a briefreport. Upsala J Med Sci 2005;110:267-273.

Nielsen JV, Jonsson E, Nilsson AK. Lasting improvement of hyperglycemia and bodyweight: low-carbohydratediet in type 2 diabetes. A brief report. Upsala J Med Sci 2005; 109:179-184.




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Recommendations SummaryDM: Sucrose and Diabetes 2008


Recommendation(s) DM: Sucrose Intake

If persons with diabetes choose to eat foods containing sucrose, the sucrose-containing foods should be substituted forother carbohydrate foods. Sucrose intakes of 10 to 35 percent of total energy intake do not have a negative effect onglycemic or lipid responses when substituted for isocaloric amounts of starch.



Excessive substitution of sucrose for starches could potentially contribute to inadequate intake of foodscontributing other essential nutrients. If sucrose-containing foods are habitually added to usual intake,excessive energy intake is a concern.


None.




Sucrose intakes of 10 percent to 35 percent of total energy intake do not have a negative effect onglycemic or lipid responses in persons with either type 1 or type 2 diabetes when sucrose is substituted forisocaloric amounts of starch.Ten randomized crossover/controlled studies (Cooper et al, 1988, Loghmani et al, 1991, Nadeau et al,2001, Peterson et al, 1986, Bantle, Laine et al, 1986, Bantle, Swanson et al, 1993, Buysschaert et al,1987, Chantelau et al, 1985, Rickard et al, 2001, Santacroce et al, 1993), four non-randomized crossoverstudies (Malerbi et al, 1996, Coulston et al, 1985, Bantle, Laine et al, 1983, Schwingshandl et al, 1994),and one cross-over study (Shimakawa et al, 1993) examined the effect of sucrose on glycemic control. Allbut one study (Coulston et al, 1985) showed no effect of sucrose.


Conclusion statement was given Grade I

Minority Opinions

Consensus reached.


What is the relationship between sucrose and metabolic outcomes in persons with type 1 and type 2 diabetes?

References Bantle JP, Laine DC, Castle GW, Thomas JW, Hoogwerf BJ, Goetz FC. Postprandial glucose and insulin responsesto meals containing different carbohydrates in normal and diabetic subjects. New Eng J Med 1983; 309:7-12.

Bantle JP, Laine DC, Thomas JW. Metabolic effects of dietary fructose and sucrose in Types I and II diabeticsubjects. JAMA 1986; 256:3241-3246.

Bantle JP, Swanson JE, Thomas W, Laine DC. Metabolic effects of dietary sucrose in type II diabetic subjects. Diabetes Care 1993; 16:1301-1305.

Buysschaert M, Sory R, Mpoy M, Lambert AE. Effect of the addition of simple sugars to mixed meals on theglycemic control of insulin treated diabetic patients. Diabete & Metabolisme 1987;13:625-629.


Chantelau EA, Gosseringer G, Sonnenberg GE, Berger M. Moderate intake of sucrose does not impair metaboliccontrol in pump-treated diabetic outpatients. Diabetologia 1985; 29(4):204-207.

Cooper PL, Wahlqvist ML, Simpson RW. Sucrose versus saccharin as an added sweetener in non-insulin-dependentdiabetes: short- and medium-term metabolic effects. Diabet Med. 1988 Oct; 5 (7): 676-680. PMID: 2975554.

Coulston AM, Hollenbeck CB, Donner CC, Williams R, Chiou YM, Reaven GM. Metabolic effects of added dietarysucrose in individuals with non-insulin-dependent diabetes mellitus (NIDDM). Metabolism 1985; 34(10):962-966.

Loghmani E, Rickard K, Washburne L, Vandagriff J, Fineberg N, Golden M. Glycemic response tosucrose-containing mixed meals in diets of children with insulin-dependent diabetes mellitus. Journal of Pediatrics1991; 119:531-537.

Malerbi DA, Duarte AL, Paiva ESA, Wajchenberg BL. Metabolic effects of dietary sucrose and fructose in Type IIdiabetic subjects. Diabetes Care 1996:1249-1256.

Nadeau J, Koski KG, Strychar I, Yale JF. Teaching subjects with type 2 diabetes how to incorporate sugar choicesinto their daily meal plan promotes dietary compliance and does not deteriorate metabolic profile. Diabetes Care2001; 24:222-227.

Peterson DB, Lambert J, Gerring S, Darling P, Carter RD, Jelfs R, Mann JI. Sucrose in the diet of diabetic patients- just another carbohydrate? Diabetologia 1986:29(4):216-220.

Rickard KA, Cleveland JL, Loghmani ES, Fineberg NS, Freidenberg GR. Similar glycemic responses to high versusmoderate sucrose-containing foods in test meals for adolescents with type 1 diabetes and fasting euglycemia. JAm Diet Assoc 2001;101:1202-1205.

Santacroce G, Forlani G, Giangiulio S, Galuppi V, Pagani M, Vannini P. Long-term effects of eating sucrose onmetabolic control of type 1 (insulin dependent) diabetic outpatients. Acta Diabetol Lat 1990; 27:365-370.

Schwingshandl J, Rippel S, Unterluggauer M, Borkenstein M. Effect of the introduction of dietary sucrose onmetabolic control in children and adolescents with type 1 diabetes. Acta Diabetol 1994; 31:205-209.

Shimakawa T, Warram JH, Herrera-Acena MG, Krolewski AS. Usual dietary intake and hemoglobin A1 level inpatients with insulin-dependent diabetes. J Am Diet Assoc 1993;93:1409-1412, 1415.


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Recommendations SummaryDM: Non-nutritive Sweeteners and Diabetes 2008


Recommendation(s) DM: Non-nutritive Sweeteners

If persons with diabetes choose to consume products containing FDA-approved non-nutritive sweeteners, at levels thatdo not exceed the ADIs, the RD should advise that some of these products may contain energy and carbohydrate fromother sources that needs to be accounted for. Research on non-nutritive sweeteners reports no effect on changes inglycemic response.

Rating: FairConditional


Nonnutritive sweeteners are safe when consumed within the daily intake levels established by the Food and DrugAdministration (FDA).


This recommendation applies to individuals with diabetes who choose to consume non-nutritive sweeteners.




In a limited number of studies, non-nutritive sweeteners had no effect on changes in blood lipid profiles


and glycemic response in adults with diabetes (Cooper et al, 1988; Mezitis et al, 1996; Grotz et al, 2003;Reyna et al, 2003; Mackenzie et al, 2006). No studies in children were identified.

In a limited number of studies conducted outside the United States, children and adults with diabetes werefound to have higher intakes of non-nutritive sweeteners as compared to controls, which did not exceedthe Acceptable Daily Intake (ADI) in most instances (Garnier-Sagne et al, 2001; Cullen et al, 2004). Theexception was Swedish children’s intakes of acesulfame-K and saccharin, which was greater than the ADIwhen “worst case” estimates were used (Ilback et al, 2003). Further studies are needed in both childrenand adults, specifically in the United States.

American Diabetes Association Recommendation: Sugar alcohols and nonnutritive sweeteners are safewhen consumed within the daily intake levels established by the Food and Drug Administration (Grade A).


Conclusion Statements were given Grade III

Minority Opinions

Consensus reached.


Can non-nutritive sweeteners (saccharin, aspartame, acesulfame-K, sucralose, neotame) be used to manage diabetes andglycemic response in people with diabetes?

What is the intake of non-nutritive sweeteners (saccharin, aspartame, acesulfame-K, sucralose, neotame) in persons withdiabetes, and is this within the Acceptable Daily Intake (ADI) of non-nutritive sweeteners?

References Cooper PL, Wahlqvist ML, Simpson RW. Sucrose versus saccharin as an added sweetener in non-insulin-dependentdiabetes: short- and medium-term metabolic effects. Diabet Med. 1988 Oct; 5 (7): 676-680. PMID: 2975554.

Grotz VL, Henry RR, McGill JB, Prince MJ, Shamoon H, Trout JR, Pi-Sunyer FX. Lack of effect of sucralose onglucose homeostasis in subjects with type 2 diabetes. J Am Diet Assoc. 2003 Dec; 103 (12): 1,607-1,612.

Mackenzie T, Brooks B, O'Connor G. Beverage Intake, Diabetes, and Glucose Control of Adults in America. AnnEpidemiol. 2006 Jan 31; [Epub ahead of print].

Mezitis NH, Maggio CA, Koch P, Quddoos A, Allison DB, Pi-Sunyer FX. Glycemic effect of a single high oral dose ofthe novel sweetener sucralose in patients with diabetes. Diabetes Care. 1996 Sep; 19 (9): 1,004-1,005.

Reyna N, Cano C, Bermudez VJ, et al. Sweeteners and beta-glucans improve metabolic and anthropometricsvariables in well controlled type 2 diabetic patients. Am J Therapeutics. 2003; 10: 438-443.

Cullen M, Nolan J, Cullen M, Moloney M, Kearney J, Lambe J, Gibney MJ. Effect of high levels of intense sweetenerintake in insulin dependent diabetics on the ratio of dietary sugar to fat: a case-control study. Eur J Clin Nutr.2004 Oct; 58 (10): 1,336-1,341. PMID: 15054410.

Garnier-Sagne I, Leblanc JC, Verger P. Calculation of the intake of three intense sweeteners in younginsulin-dependent diabetics. Food Chem Toxicol. 2001 Jul; 39 (7): 745-749.

Ilback NG, Alzin M, Jahrl S, Enghardt-Barbieri H, Busk L. Estimated intake of the artificial sweetenersacesulfame-K, aspartame, cyclamate and saccharin in a group of Swedish diabetics. Food Additives andContaminates, 2003 Feb; 20 (2): 99-114.





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Recommendations SummaryDM: Glycemic Index and Diabetes 2008



Recommendation(s) DM: Glycemic Index

If the use of glycemic index is proposed as a method of meal planning, the RD should advise on the conflicting evidenceof effectiveness of this strategy. Studies comparing high versus low GI diets report mixed effects on A1C.



None.


None.




Fifteen short-term studies ranging from two to 12 weeks and one longer term (one year) studies reportmixed effects on A1C levels (Wolever et al, 1991, 1992, 1994, and 1999; Fontvielle et al, 1992; Frost etal, 1994; Jarvi et al, 1999; Buyken et al, 2001; Gilbertson et al, 2001 and 2003; Helbronn et al, 2002;Kabir et al, 2002; Brand-Miller et al, 2003; Rizkalla et al, 2004; Burani et al, 2006). These studies are complicated by differing definitions of "high GI" and "low GI" diets or quartiles, as wellas possible confounding dietary factors.


Conclusion statement given Grade II.

Minority Opinions

Consensus reached.


What is the relationship between glycemic index and metabolic outcomes in persons with type 1 and type 2 diabetes?

References Brand-Miller J, Petocz P, Hayne S, Colagiuri S. Low-glycemic index diets in the management of diabetes: ameta-analysis of randomized controlled trials. Diabetes Care 2003; 26:2261-2267.

Burani J, Longo P. Low glycemic index carbohydrates: an effective behavioral change for glycemic control andweight management in patients with type 1 and 2 diabetes. The Diabetes Educator 2006; 32:78-88.

Buyken AE, Toeller M, Heitkamp G, Karamanos B, Rottiers R, Muggeo M, Fuller JH. Glycemic index in the dietof European outpatients with type 1 diabetes: relations to glycated hemoglobin and serum lipids. Am J clin Nutr2001; 73:574-581.

Fontvieille AM, Rizkalla SW, Penfornis A, Acosta M, Bornet FRJ, Slama G. The use of low glycemic index foodsimproves metabolic control of diabetic patients over five weeks. Diabet Med 1992;9(5):444-50.

Frost G, Wilding J, Beecham J. Dietary advice based on the glycemic index improves dietary profile and metaboliccontrol in type 2 diabetic patients. Diabet Med 1994;11(4):397-401.

Gilbertson HR, Thorburn AW, Brand-Miller JC, Chondros P, Werther GA. Effect of low-glycemic-index dietary adviceon dietary quality and food choice in children with type 1 diabetes. Am J Clin Nutr 2003; 77:83-90.

Gilbertson HR, Brand-Miller JC, Thorburn AW, Evans S, Chondros P, Werther GA. The effect of flexible lowglycemic index dietary advice versus measured carbohydrate exchange diets on glycemic control in children withtype 1 diabetes. Diabetes Care. 2001;24:1137-1143.

Heilbronn LK, Noakes M, Clifton PM. The effect of high- and low-glycemic index energy restricted diets on plasmalipid and glucose profiles in type 2 diabetic subjects with varying glycemic control. J Am Coll Nutr 2002;21:120-127.

Jarvi AE, Karlstrom BE, Granfeldt YE, Bjorck IE, Asp NGL, Vessby BOH. Improved glycemic control and lipid profileand normalized fibrinolytic activity on a low glycemic index diet in type 2 diabetic patients. Diabetes Care. 1999;22: 10-18.

Kabir M, Oppert JM, Vidal H, Bruzzo F, Fiquet C, Wursch P, Slama G, Rizkalla SW. Four-week low-glycemic index


breakfast with a modest amount of soluble fibers in type 2 diabetic men. Metabolism 2002; 51:819-826.

Rizkalla SW, Boillot J, Taghrid L, Rigoir A, Laromiguiere M, Elgrably F, Huet D, Slama G. Improved plasmaglucose control, whole-body glucose utilization, and lipid profile on a low-glycemic index diet in type 2 diabeticmen: a randomized controlled trial. Diabetes Care 2004; 27:1866-1872.

Wolever TMS, Jenkins DJA, Jenkins AL, Josse RG. The glycemic index: methodology and clinical implications. AmJ Clin Nutr. 1991;54:846-854.


Wolever TMS, Nguyen PM, Chiasson JL, Hunt JA, Josse RG, Palmason C, Rodger NW, Ross SA, Ryan EA, Tan MH. Determinants of diet glycemic index calculated retrospectively from diet records of 342 individuals withnon-insulin-dependent diabetes mellitus. Am J Clin Nutr. 1994;59:1265-1269.

Wolever TMS, Jenkins DJA, Vuksan V, Jenkins AL, Buckley GC, Wong GS, Josse RG. Beneficial effect of a lowglycemic index diet in type 2 diabetes. Diabet Med 1992;9(5):451-8.

Diabetes Type 1 and 2



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Recommendations SummaryDM: Protein and Diabetes 2008


Recommendation(s) DM: Protein Intake and Normal Renal Function

In persons with type 1 or type 2 diabetes with normal renal function, the RD should advise that usual protein intake ofapproximately 15 to 20% of daily energy intake does not need to be changed. Although protein has an acute effect oninsulin secretion, usual protein intake in long-term studies has minimal effects on glucose, lipids, and insulinconcentrations.


DM: Protein Intake and Nephropathy

In persons with diabetic nephropathy, a protein intake of one gram or less per kg body weight per day isrecommended. Diets with less than one gram protein per kg body weight per day have been shown to improvealbuminuria in persons with nephropathy; however, they have not been shown to have significant effects on glomerularfiltration rates (GFR).


DM: Protein Intake and Late Stage Nephropathy

For persons with late stage diabetic nephropathy (Chronic Kidney Disease [CKD] Stages 3-5), hypoalbuminemia (anindicator of malnutrition) and energy intake must be monitored and changes in protein and energy intake made tocorrect deficits. A protein intake of approximately 0.7 grams per kg body weight per day has been associated withhypoalbuminemia, whereas a protein intake of approximately 0.9 grams per kg body weight per day has not.



Diets too low in protein and energy intakes can lead to hypoalbuminemia (malnutrition) and unintentionalweight loss. This needs to be monitored in persons with diabetic nephropathy who are restricting proteinintake and may have a diminished appetite.


In persons with diabetic nephropathy, hypoalbuminemia and weight must be monitored.


Protein intake of approximately 0.6 g/kg/d or lower often requires purchase and use of low-protein foods.This can contribute to the cost of food.Although costs of MNT sessions and reimbursement vary, medical nutrition therapy sessions are essentialfor improved outcomes.


The amount of protein consumed at meals has minimal influence onglycemic response, on lipids, on hormones and metabolites, and shows no long-term effect on insulinrequirements.Two single meal studies (Nordt et al, 1991; Gannon et al, 2001) report an acute insulin response toingestion of protein. However, three studies (Luscombe et al, 2002; Parker et al, 2002; Gannon et al, 2003) based on higherprotein diets (30% of energy from protein) lasting five to twelve weeks showed no significant difference inlonger-term insulin response; one study (Gannon et al, 2003) showed a significant decrease in A1C. As the percentage of energy from protein is increased and the percentage of energy from fat remainsconstant, the percentage of energy from carbohydrate is decreased, and therefore it is difficult todetermine whether higher protein intakes or lower carbohydrate intakes result in significant effects onmetabolic outcomes. Six positive-quality randomized controlled trials based on lower protein diets in the management ofdiabetic nephropathy report inconclusive findings; in all six studies this may be a result of poor compliance


with reduction in protein intake (Raal et al, 1994; Hansen et al, 1999; Hansen et al, 2002; Meloni et al,2002; Pijls et al, 2002; Meloni et al, 2004). In the two studies that were able to compare protein levels greater than 1.0 g/kg/day with protein intakesof 0.8 g/kg/day or lower, the lower protein diets significantly improved albuminuria but had no significanteffects on glomerular filtration rate (Hansen et al, 1999, Meloni et al, 2002). The other four studies found no significant difference between groups in either albumin excretion rate orglomerular filtration rate.In two studies, hypoalbuminemia was associated with an actual protein intake of ~0.7 g/kg/d (Meloni etal, 2002), but not at a protein intake of ~0.9 g/kg/day (Meloni et al, 2004). American Diabetes Association Recommendation: For individuals with diabetes and normal renal function,there is insufficient evidence to suggest that usual protein intake (15-20% of energy) should be modified(Grade E).


Conclusion Statements were given Grade II

Minority Opinions

Consensus reached.


What is the relationship between protein intake and metabolic outcomes in persons with type 1 and type 2 diabetes?

What is the evidence that protein restriction (with or without amino acid or ketoacid supplementation) is an effectivetreatment of patients with diabetic nephropathy?

References Gannon MC, Nuttall JA, Damberg G, Gupta V, Nuttall FQ. Effect of protein ingestion on the glucose appearancerate in people with type 2 diabetes. J Clin Endocrin Metab. 2001;86:1040-1047.

Gannon MC, Nuttall FQ, Saeed A, Jordan K, Hoover H. An increase in dietary protein improves the blood glucoseresponse in persons with type 2 diabetes. Am J Clin Nutr. 2003;78:734-741.

Luscombe ND, Clifton PM, Noakes M, Parker B, Wittert G. Effects of energy-restricted diets containing increasedprotein on weight loss, resting energy expenditure, and the thermic effect of feeding in type 2 diabetes. DiabetesCare 2002;25:652-657

Nordt TK, Besenthal I, Eggstein M, Jakober B. Influence of breakfasts with different nutrient contents on glucose,C peptide, insulin, glucagon, triglycerides, and GIP in non-insulin-dependent diabetics. Am J Clin Nutr.1991;53:155-160.

Nuttall FQ, Gannon MC, Saeed A, Jordan K, Hoover H. The metabolic response of subjects with type 2 diabetes toa high-protein, weight-maintenance diet. J Clin Endocrinol Metab. 2003;88:3577-3583.


Azadbakht L, Shakerhosseini R, Atabak S, Jamshidian M, Mehrabi Y, Esmaill-Zadeh A. Beneficiary effect of dietarysoy protein on lowering plasma levels of lipid and improving kidney function in type II diabetes with nephropathy.Eur J Clin Nutr 2003;57:1292-1294.

Hansen HP, Christensen PK, Tauber-Lassen E, Klausen A, Jensen BR, Parving H. Low-protein diet and kidneyfunction in insulin-dependent diabetic patients with diabetic nephropathy. Kidney International. 1999;55:621-628.

Hansen HP, Tauber-Lassen E, Jensen BR, Parving H-H. Effect of dietary protein restriction on prognosis in patientswith diabetic nephropathy. Kidney Int 2002:61:220-228.

Meloni C, Morosetti M, Suraci C, Pennafina MG, Tozzo C, Taccone-Gallucci M, Casciani CU. Severe dietary proteinrestriction in overt diabetic nephropathy: Benefits or risks? J Renal Nutr 2002;12:96-101.

Meloni C, Tatangelo P, Cipriani S, Rossi V, Suraci C, Tozzo C, Rossini B, Cecilia A, DiFranco D, Straccialano E,Casciani CU. Adequate protein dietary restriction in diabetic and nondiabetic patients with chronic renal failure. Journal of Renal Nutrition 2004; 14 (4): 208-213.

Pijls LTJ, de Vries H, van Eijk JThM, Donker AJM. Protein restriction, glomerular filtration rate and albuminuria inpatients with type 2 diabetes mellitus: a randomized trial. Eur J Clin Nutr. 2002;56:1200-1207.

Pijls LTJ, de Vries H, Kriegsman DMW, Donker AJM, van Eijk JThM. Determinants of albuminuria in people withType 2 diabetes mellitus. Diabetes Res Clin Pract. 2001:52:133-143.

Raal FJ, Kalk WJ, Lawson M, Esser JD, Buys R, Fourie L, Panz VR. Effect of moderate dietary protein restriction onthe progression of overt diabetic nephropathy: a 6-month prospective study. Am J Clin Nutr. 1994;60:579-585.

Stojceva-Taneva O, Polenakovic M, Grozdanovski R, Sikole A. Lipids, protein intake and progression of diabeticnephropathy. Nephrol Dial Transplant. 2001; 16[suppl 1]: 90-91.






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Recommendations SummaryDM: Glucose Monitoring 2008


Recommendation(s) DM: Blood Glucose Monitoring

For individuals on nutrition therapy alone or nutrition therapy in combination with glucose-lowering medications,self-monitoring of blood glucose (SMBG) is recommended. Frequency and timing is dependent on diabetes managementgoals and therapies (i.e. MNT, diabetes medications and physical activity). When SMBG is incorporated into diabeteseducation programs and the information from SMBG is used to make changes in diabetes management, SMBG isassociated with improved glycemic control.


DM: Frequency of Blood Glucose Monitoring

For persons with type 1 or type 2 diabetes on insulin therapy, at least three to eight blood glucose tests per day arerecommended to determine the adequacy of the insulin dose(s) and guide adjustments in insulin dose(s), food intake andphysical activity. Some insulin regimens require more testing to establish the best integrated therapy (insulin, food, andactivity). Once established, some insulin regimens will require less frequent self-monitoring of blood glucose (SMBG).Intervention studies that include self-management training and adjustment of insulin doses based on SMBG result inimproved glycemic control.


DM: Possible Need for Continuous Glucose Monitoring or More Frequent SMBG

Persons experiencing unexplained elevations in A1C or unexplained hypoglycemia and hyperglycemia may benefit fromuse of continuous glucose monitoring (CGM) or more frequent SMBG. It is essential that persons with diabetes receiveeducation as to how to calibrate CGM and how to interpret CGM results. Studies have proven the accuracy of CGM andmost show that using the trend/pattern data from CGM can result in less glucose variability and improved glucose control.



SMBG:

Frequent glucose self-monitoring may cause pain and discomfortIndividuals should know of proper disposal of hazardous waste


SMBG:

Persons must receive education and training in order to use the SMBG devices and data correctly.

CGM:

Persons must receive more comprehensive education and training in order to use the CGM devices anddata correctly.In order to have accurate glucose readings, individuals using CGM must be able to correctly calibrate themonitors as indicated by the specific device. Calibration must be done when glucose levels are stable(e.g., it should not be done when a person is eating or exercising). Users must also understand thedifference in interstitial fluid tests compared to single point measurement of blood tests and lag time. Thisis especially critical when glucose levels are dropping. To accurately detect and treat hypoglycemia,capillary blood tests should be used.Currently, the Food and Drug Administration has approved CGM for diagnostic use (e.g., tracking trends inglucose levels), not for making treatment decisions. Treatment decisions should be confirmed using acapillary blood glucose test.CGM devices have alarms to alert the user of hypoglycemia. The intent of the alarm is to enable the userto detect when blood glucose levels are dropping and must be verified by single point measurements of


blood glucose to confirm hypoglycemia. If hypoglycemia is verified, treatment must be provided. Falsenegative alarms and alarm delays due to lag time are a concern.Reimbursement for medical supplies may be a barrier. The scope of practice of the RD and the standards of professional performance defines the role of the RDin glucose self-monitoring education.


There are costs involved in the purchasing of blood glucose monitors and supplies.Insurance reimbursement varies from state-to-state. Medicare provides somereimbursement. Although costs vary, educational sessions on how to use the data fromself-monitoring of blood glucose are essential. Elevated blood glucose levels (sub-optimal control) or hypoglycemic episodes canlead to costly health complications. The cost of education and supplies is less thanthat of treating complications. Both the initial and ongoing costs for CGM are high. Limited coverage is availableand reimbursement decisions are usually made case-by-case.


In subjects with diabetes, studies have shown that self-monitoring of blood glucose (SMBG) valuescorrelate with A1C values (Brewer et al, 1998; Bonora et al, 2001; Hoffman et al, 2002; Fiallo-Scharer etal, 2005). Prospective intervention studies in subjects with type 1 diabetes that included self-management trainingand adjustment of insulin doses based on SMBG showed significant improvement in glycemic controlcompared to study control group (DAFNE Study Group, 2002; DCCT, 1993). More frequent SMBG (3 to 8 times daily) was also associated with better glycemic control regardless ofdiabetes type or therapy (Karter et al, 2001).SMBG, compared to non-SMBG, is associated with greater improvement in A1C when it is a part of astructured education program where subjects use the information to make changes in theirmanagement program (Allen et al, 1990; Franciosi et al, 2001; Schwedes et al, 2002; Davidson et al,2005; Sarol et al 2005). Evidence on frequency and duration of SMBG is inconclusive (Coster et al, 2000; Harris, 2001; Karter etal, 2001; Meier et al, 2002; Murata et al, 2003; Jaworska et al, 2004; Wen et al, 2004; Franciosi et al,2005; Martin et al, 2006).Six studies (3 RCTs, 3 time series) using continuous glucose monitoring (CGM) in subjects with diabetesreport improvements in glycemic control (Kaufman et al, 2001; Chico et al, 2003; Ludvigsson et al, 2003;Schaepelynck-Belicar et al, 2003; Deiss et al, 2004; Tanenberg et al, 2004).Seven studies (4 RCTs, 2 time series, 1 nonrandomized trial) report improvements in hyper- andhypoglycemic ranges (Schiaffini et al, 2002; Schaepelynck-Belicar et al, 2003; Bode et al, 2004; Garg etal, 2004; Tanenberg et al, 2004; Weintrob et al, 2004; Garg et al, 2006).Data derived from CGM can be used to modify food or insulin therapy that will improve metabolicoutcomes; however, it is currently unclear if use of information from CGM will improve metabolicoutcomes significantly more than use of information derived from SMBG: two RCTs (Chico et al, 2003;Tanenberg et al, 2004) found that both methods significantly improved A1C; one RCT (Ludvigsson et al,2003) found that only CGM significantly improved A1C; and one RCT (Garg et al, 2006) found that only CGM significantly reduced hyperglycemia.In a data-gathering study (Fiallo-Scharer et al, 2005), both methods gave similar mean glucose profilesand associations with A1C.Two RCTs (Chico et al, 2003; Ludvigsson et al, 2003) found no significant differences between methods inimproving hypoglycemia; however two other RCTs (Tanenberg et al, 2004; Garg et al, 2006) found that CGM reduced duration of hypoglycemia vs. SMBG.Five studies (1 observational, 2 cross-sectional, and 2 case series) present pattern information from thewearing of CGM devices (Boland et al, 2001; Alemzadeh et al, 2003; Manuel-y-Keenoy et al,2004; Bode et al, 2005; Streja et al, 2005).


Conclusion Statements given Grades I and II

Minority Opinions

Consensus reached.


What is the relationship between self-monitoring of blood glucose and metabolic outcomes in persons with type 1diabetes?

What is the relationship between self-monitoring of blood glucose and metabolic outcomes in persons with type 2diabetes?

What is the relationship between continuous glucose monitoring and metabolic outcomes in persons with type 1 and type2 diabetes?

References


Bonora E, Calcaterra F, Lombardi S, Bonfante N, Formentini G, Bonadonna RC, Muggeo M. Plasma Glucose LevelsThroughout the Day and HbA1c Interrelationships in Type 2 Diabetes: Implications for treatment and monitoringof metabolic control. Diabetes Care 2001;24: 2023-2029.

Brewer KW, Chase HP, Owen S, Garg SK. Slicing the pie: correlating HbA1C values with average blood glucosevalues in a pie chart form. Diabetes Care. 1998;21:209-212.



Fiallo-Scharer R, Xing D, Weinzimer S, Buckingham B, Mauras N, Tansey M, Chase P, Beck R, Ruedy K, Kollman C,Tamborlane W. Eight-Point Glucose Testing Versus the Continuous Glucose Monitoring System in Evaluation ofGlycemic Control in Type 1 Diabetes. J Clin Endocrinol Metab. 2005; 90: 3,387-3,391.

Hoffman RM, Shah JH, Wendel CS, Duckworth WC, Adam KD, Bokhari SU, Dalton C, Murata GH. EvaluatingOnce- and Twice-Daily Self-Monitored Blood Glucose Testing Strategies for Stable Insulin-Treated Patients withType 2 Diabetes. The Diabetes Outcomes in Veterans Study. Diabetes Care 2002;25: 1744-1748.

Karter AJ, Ackerson LM, Darbinian JA, D’Agostino RB Jr, Ferrara A, Liu J, Selby JV. Self-monitoring of bloodglucose levels and glycemic control: the Northern California Kaiser Permanente Diabetes registry. Am J Med.2001; 111:1-9.

Alemzadeh R, Loppnow C, Parton E, Kirby M. Glucose sensor evaluation of glycemic instability in pediatric type 1diabetes mellitus. Diabetes Technology & Therapeutics. 2003;5(2):167-173.

Bode B, Gross K, Rikalo N, Schwartz S, Wahl T, Page C, Gross T, Mastrototaro J. Alarms based on real-timesensor glucose values alert patients to hypo- and hyperglycemia: the Guardian Continuous Monitoing System. Diabetes Technology & Therapeutics. 2004:6(2):105-113.

Bode BW, Schwartz S, Stubbs HA, Block JE. Glycemic characteristics in continuously monitored patients with type1 and type 2 diabetes. Diabetes Care, 2005; 28 (10): 2,361-2,366.

Boland E, Monsod T, Delucia M, Brandt CA, Fernando S, Tamborlane WV. Limitations of conventional methods ofself-monitoring of blood glucose. Diabetes Care 2001; 24: 1858-1862.

Chico A, Vidal-Rios P, Subira M, Novials A. The continuous glucose monitoring system is useful for detectingunrecognized hypoglycemias in patients with type 1 and type 2 diabetes but is not better than frequent capillaryglucose measurements for improving metabolic control. Diabetes Care. 2003;26:1153-1157.

Deiss D, Hartmann R, Hoeffe J, Kordonouri O. Assessment of glycemic control by continuous glucose monitoringsystem in 50 children with type 1 diabetes starting on insulin pump therapy. Pediatric Diabetes. 2004;5:117-121.


Garg SK, Schwartz S, Edelman SV. Improved glucose excursions using an implantable real-time continuousglucose sensor in adults with type 1 diabetes. Diabetes Care. 2004;27:734-738.

Garg S, Zisser H, Schwartz S, Bailey T, Kaplan R, Ellis S, Jovanovic L. Improvement in glycemic excursions with atranscutaneous, real-time continuous glucose sensor: a randomized controlled trial. Diabetes Care 2006; 29(1):44-50.

Kaufman FR, Gibson LC, Halvorson M, Carpenter S, Fisher LK, Pitukcheewanont P. A pilot study of the continuousglucose monitoring system: clinical decisions and glycemic control after its use in pediatric type 1 diabeticsubjects. Diabetes Care. 2001;24(12):2030-2034.

Ludvigsson J, Hanas R. Continuous subcutaneous glucose monitoring improved metabolic control in pediatricpatients with type 1 diabetes: a controlled crossover study. Pediatrics. 2003;111(5):933-938.

Manuel-y-Keenoy B, Vertommen J, Abrams P, Van Gaal L, De Leeuw I, Messeri D, Poscia A. Postprandial glucosemonitoring in type 1 diabetes mellitus: use of a continuous subcutaneous monitoring device. Diabetes Metab ResRev. 2004;20 (Suppl 2):S24-S31.

Schaepelynck-Belicar P, Vague Ph, Simonin G, Lassmann-Vague V. Improved metabolic control in diabeticadolescents using the continuous glucose monitoring system (CGMS). Diabetes Metab. 2003;29:608-612.

Schiaffini R, Ciampalini P, Fierabracci A, Spera S, Borrelli P, Bottazzo GF, Crino A. The continuous glucosemonitoring system (CGMS) in type 1 diabetic children is the way to reduce hypoglycemic risk. Diabetes Metab ResRev. 2002;18:324-329.

Streja D. Can continuous glucose monitoring provide objective documentation of hypoglycemia unawareness?.Endocrine Practice 2005;11(2):83-90.

Tanenberg R, Bode B, Lane W, Levetan C, Mestman J, Harmel AP, Tobian J, Gross T, Mastrototaro J. Use of thecontinuous glucose monitoring system to guide therapy in patients with insulin-treated diabetes: a randomizedcontrolled trial. Mayo Clin Proc. 2004;79 (12):1521-1526.

Weintrob N, Schechter A, Benzaquen H, Shalitin S, Lilos P, Galatzer A, Phillip M. Glycemic patterns detected bycontinuous subcutaneous glucose sensing in children and adolescents with type 1 diabetes mellitus treated bymultiple daily injections vs continuous subcutaneous insulin infusion. Arch Pediatr Adolesc Med.2004;158:677-684.

Allen BT, DeLong ER, Feussner JR. Impact of glucose self-monitoring on non-insulin-treated patients with type IIdiabetes mellitus. Randomized controlled trial comparing blood and urine testing. Diabetes Care. 1990; 13:


1044-1050.

Bonora E, Calcaterra F, Lombardi S, Bonfante N, Formentini G, Bonadonna RC, Muggeo M. Plasma Glucose LevelsThroughout the Day and HbA1c Interrelationships in Type 2 Diabetes: Implications for treatment and monitoringof metabolic control. Diabetes Care 2001;24: 2023-2029.

Brewer KW, Chase HP, Owen S, Garg SK. Slicing the pie: correlating HbA1C values with average blood glucosevalues in a pie chart form. Diabetes Care. 1998;21:209-212.

Coster S, Gulliford MC, Seed PT, Powrie JK, Swaminathan R. Self-monitoring in type 2 diabetes mellitus: ameta-analysis. Diabetic Medicine. 2000; 17: 755-761.

Davidson MB, Castellanos M, Kain D, Duran P. The effect of self monitoring of blood glucose concentrations onglycated hemoglobin levels in diabetic patients not taking insulin: A blinded, randomized trial. Am J Medicine2005;118(4):422-5.


Franciosi M, Pellegrini F, DeBerardis G, Belfiglio M, Cavaliere D, DiNardo B, Greenfield S, Kaplan SH, Sacco M,Tognoni G, Valentini M, Nicolucci A, for The QuED Study Group. The Impact of Blood Glucose Self-Monitoring onMetabolic Control and Quality of Life in Type 2 Diabetic Patients: An urgent need for better educational strategies. Diabetes Care 2001;24(11):1870-7.

Franciosi M, Pellegrini F, DeBerardis G, Belfiglio M, DiNardo B, Greenfield S, Kaplan SH, Rossi MCE, Sacco M,Tognoni G, Valentini M, Nicolucci A. for The QuED Study Group- quality of care and outcomes in Type 2 diabetes. Self-monitoring of blood glucose in non-insulin-treated diabetic patients: a longitudinal evaluation of its impact onmetabolic control. Diabetes Medicine 2005; 22: 900-906.

Harris MI. Frequency of blood glucose monitoring in relation to glycemic control in patients with type 2 diabetes. Diabetes Care, 2001; 24 (6): 979-982.

Hoffman RM, Shah JH, Wendel CS, Duckworth WC, Adam KD, Bokhari SU, Dalton C, Murata GH. EvaluatingOnce- and Twice-Daily Self-Monitored Blood Glucose Testing Strategies for Stable Insulin-Treated Patients withType 2 Diabetes. The Diabetes Outcomes in Veterans Study. Diabetes Care 2002;25: 1744-1748.

Jaworska J, Dziemidok P, Kulik TB, Rudnicka-Drozak E. Frequency of self-monitoring and its effect on metaboliccontrol in patients with type 2 diabetes. Ann Univ Mariae Curie Sklodowsk (Med) 2004; 59(1): 310-6.

Karter AJ, Ackerson LM, Darbinian JA, D’Agostino RB Jr, Ferrara A, Liu J, Selby JV. Self-monitoring of bloodglucose levels and glycemic control: the Northern California Kaiser Permanente Diabetes registry. Am J Med.2001; 111:1-9.

Martin S, Schneider B, Heinemann L, Lodwig V , Kurth HJ, Kolb H, Scherbaum WA, for the ROSSO Study Group.Self-monitoring of blood glucose in type 2 diabetes and long-term outcome: an epidemiological cohort study.Diabetologia, 2006; 49: 271-278.

Meier JL, Swislocki ALM, Lopez JR, Noth RH, Bartlebaugh P, Siegel D. Reduction in self-monitoring of bloodglucose in persons with type 2 diabetes results in cost savings and no change in glycemic control. Am J ManagCare. 2002; 8: 557-565.

Murata GH, Shah JH, Hoffman RM, Wendel CS, Adam KD, Solvas PA, Bokhari SU, Duckworth WC. IntensifiedBlood Glucose Monitoring Improves Glycemic Control in Stable, Insulin-Treated Veterans With Type 2 Diabetes:The Diabetes Outcomes in Veterans Study (DOVES). Diabetes Care 2003;26: 1759-1763.

Sarol Jr JN, Nicodemus Jr NA, Tan KM, Grava MB. Self-monitoring of blood glucose as part of a multi-componenttherapy among non-insulin requiring type 2 diabetes patients: a meta-analysis (1966-2004). Current MedicalResearch and Opinion 2005;21(2):173-184.

Schwedes U, Siebolds M, Mertes G, For the SMBG Study Group. Meal-Related Structured Self-Monitoring of BloodGlucose: Effect on diabetes control in non-insulin-treated type 2 diabetic patients. Diabetes Care 2002;25:1928-1932.

Wen L, Parchman ML, Linn WD, Lee S. Association between self-monitoring of blood glucose and glycemic controlin patients with type 2 diabetes mellitus. Am J Health Syst Pharm 2004; 61:2401-5.


Kulkarni K, Boucher J, Daly A, Shwide-Slavin C, Silvers B, O’Sullivan Maillet J. AmericanDietetic Association: Standards of Practice and Standards of Professional Performance for Registered Dietitians(Generalist, Specialty, and Advanced) in Diabetes Care. J Am Diet Assoc. 2005;105:820-824.


Quick Links

Recommendations SummaryDM: Prevention and Treatment of CVD 2008

Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels



Recommendation(s) DM: CVD and Cardioprotective Nutrition Therapy

Cardioprotective nutrition interventions for the prevention and treatment of cardiovascular disease (CVD) should beimplemented in the initial series of encounters. Diabetes is associated with an increased risk for CVD and glycemiccontrol may improve the lipid profile.


DM: CVD and Cardioprotective Nutrition Interventions

Cardioprotective nutrition interventions for prevention and treatment of CVD include reduction in saturated and trans fatsand dietary cholesterol, and interventions to improve blood pressure. Studies in persons with diabetes utilizing theseinterventions report a reduction in cardiovascular risk and improved cardiovascular outcomes.



None.


None.


Although costs of MNT sessions and reimbursement vary, medical nutrition therapysessions are essential for improved outcomes.


Diabetes is associated with increased risk of complications related to CVD(Mayer-Davis et al, 1999; Mukamal et al, 2001; Orchard et al, 2001; Selvin et al,2004; Faulkner et al, 2006). Nutrition interventions lasting 1 year or more, such as Mediterranean dietarypatterns (Ciccarone et al, 2003; Diakoumopoulou et al, 2005) and multifactorialinterventions, reduced A1C, blood pressure and body weight and improved serumlipid profile (DCCT, 1993; Turner et al, 1998; Dhindsa et al, 2003; Gaede et al, 2003;Gill et al, 2003), all of which reduce the risk for the development of cardiovasculardisease.Three studies (Yu-Poth et al, 1999; Krook et al, 2003; Perassolo et al, 2004) showedimprovements in lipid profiles from cardioprotective nutrition interventions. Eight studies (Storm et al, 1997; Lovejoy et al, 2002; Gerhard et al, 2004; Neyestaniet al, 2004; Mostad et al, 2004; Rodriguez-Villar et al, 2004; Tapsell et al, 2004;West et al, 2005) reported benefits from specific fatty acids and low-fat diets. Two studies (Didangelons et al, 2004; Osende et al, 2004) implementing MNT anddrug therapies reported lower A1C levels and improvement in vascular risk factors. Two studies (Karantonis et al, 2006; Mantzoros et al, 2006) found that in personswith diabetes adherence to a Mediterranean-type diet lead to positive outcomes. Two studies (Houlihan et al, 2002; Vedovato et al, 2004) reported benefits on bloodpressure from low-sodium diets.


Conclusion Statements were given Grade I

Minority Opinions

Consensus reached.



Are there specific nutrition interventions (for at least 1 year) in the prevention of cardiovascular disease in people withdiabetes?

Are there specific nutrition interventions in the treatment of cardiovascular disease in people with diabetes?

References Ciccarone E, Di Castelnuovo A, Salcuni M, Siani M, Giacco A, Donati MB, De Gaetano G, Capani F, Iacoviello L,Gendiabe Investigators. A high-score Mediterranean dietary pattern is associated with a reduced risk of peripheralarterial disease in Italian patients with Type 2 diabetes. J Thromb Haemost 2003;1(8):1744-52.


Dhindsa P, Scott AR, Donnelly R. Metabolic and cardiovascular effects of very-low-calorie diet therapy in obesepatients with Type 2 diabetes in secondary failure: outcomes after 1 year. Diabet Med 2003;20(4):319-24.

Diakoumopoulou E, Tentolouris N, Kirlaki E, Perrea D, Kitsou E, Psallas M, Doulgerakis D, Katsilambros N. Plasmahomocysteine levels in patients with type 2 diabetes in a Mediterranean population: relation with nutritional andother factors. Nutrition, Metabolism & Cardiovascular Diseases 2005; 15: 109-117.

Faulkner MS, Chao W, Kamath SK, Quinn L, Fritschi C, Maggiore JA, Williams RH, Reynolds RD. Totalhomocysteine, diet, and lipid profiles in type 1 and type 2 diabetic and nondiabetic adolescents. J ofCardiovascular Nursing 2006; 21: 47-55.

Gaede P, Vedel P, Larsen N, Jensen GV, Parving HH, Pedersen O. Multifactorial intervention and cardiovasculardisease in patients with type 2 diabetes. N Engl J Med 2003;348(5):383-93.

Gill GV, Woodward A, Pradhan S, Wallymahmed M, Groves T, English P, Wilding JP. Intensified treatment of type2 diabetes--positive effects on blood pressure, but not glycaemic control. Q J Med 2003; 96:833-836.

Mayer-Davis EJ, Levin S, Marshall JA. Heterogeneity in associations between macronutrient intake and lipoproteinprofile in individuals with type 2 diabetes. Diabetes Care 1999;22:1632-1639.

Mukamal KJ, Nesto RW, Cohen MC, Muller JE, Maclure M, Sherwood JB, Mittleman MA. Impact of diabetes onlong-term survival after acute myocardial infarction. Comparability of risk with prior myocardial infarction. Diabetes Care. 2001;24:1422-1427.

Orchard TJ, Forrest KY, Kuller LH, Becker DJ. Lipid and blood pressure treatment goals for type 1 diabetes:10-year incidence data from the Pittsburgh Epidemiology of Diabetes Complications Study. Diabetes Care. 2001;24:1053-1059.

Selvin E, Marinopoulos S, Berkenblit G, Rami T, Brancati FL, Powe NR, Golden SH. Meta-analysis: glycosylatedhemoglobin and cardiovascular disease in diabetes mellitus. Annals of Internal Medicine 2004; 141: 421-431.

Turner RC, Millns H, Neil HAW, Stratton IM, Manley SE, Matthews DR, Holman RR. Risk factors for coronary arterydisease in non-insulin dependent diabetes mellitus: United Kingdom prospective diabetes study (UKPDS: 23). BMJ. 1998; 316: 823-828.

Didangelos TP, Thanapoulou AK, Bousboulas SH, Sambanis CL, Athyros VG, Spanou EA, Dimitriou KC, Pappas SI,Karamanos BG, Karamitsos DT. The ORLIstat and CArdiovascular risk profile in patients with metabolic syndromeand type 2 DIAbetes (ORLICARDIA) study. Current Medical Research and Opinion 2004; 20:1393-1401.


Houlihan CA, Casley DJ, Allen TJ, Cooper ME, Baxter AL, Jerums G, Panangiotopoulos S. a low-sodium dietpotentiates the effects of Losartan in type 2 diabetes. Diabetes Care 2002; 25:663-671.

Karantonis HC, Fragopoulou E, Antonopoulou S, Rementzis J, Phenekos C, Demopoulos CA. Effect of fast-foodMediterranean-type diet on type 2 diabetics and healthy human subjects' platelet aggregation. DiabetesResearch and Clinical Practice 2006; 72:33-41.

Krook A, Holm I, Pettersson S, Wallberg-Henriksson H. Reduction of risk factors following lifestyle modificationprogramme in subjects with type 2 (non-insulin dependent) diabetes mellitus. Clinical Physiology and FunctionalImaging 2003; 23:21-30.

Lee YM, Haastert B, Scherbaum W, Hauner H. A phytosterol-enriched spread improves the lipid profile of subjectswith type 2 diabetes mellitus. Eur J Nutr 2003; 42:111-117.

Lonn E, Dagenais G, Yusuf S, Mann JFE, Hoogwerf B, Gerstein HC, Pogue J, Qilong Y, Zinman B, Bosch J. Effectsof vitamin E on cardiovascular and microvascular outcomes in high-risk patients with diabetes: results of theHOPE Study and MICRO-HOPE Substudy. Diabetes Care 2002; 25:1919-1927.

Lovejoy JC, Most MM, Lefevre M, Greenway FL, Rood JC. Effect of diets enriched in almonds on insulin action andserum lipids in adults with normal glucose tolerance or type 2 diabetes. Am J Clin Nutr 2002; 76:1000-1006.

Mantzoros CS, Williams CJ, Manson JE, Meigs JB, Hu FB. Adherence to the Mediterranean dietary pattern ispositively associated with plasma adiponectin concentrations in diabetic women. Am J Clin Nutr 2006; 84:328-335.

Mostad IL, Qvigstad E, Bjerve KS, Grill VE. Effects of a 3-day low-fat diet on metabolic control, insulin sensitivity,lipids, and adipocyte hormones in Norwegian subjects with hypertriacylglycerolaemia and type 2 diabetes. Scand J


Clin Lab Invest 2004; 64:565-574.

Neyestani TR, Alipour-Birgani R, Siassi F, Rajayi M, Djalali M, Mohamadi M. Glycemic optimization may reducelipid peroxidation independent of weight and blood lipid changes in Type 2 diabetes mellitus. Diab Nutr Metab2004; 17:275-279.

Osende JI, Badimon JJ, Fuster V, Herson P, Rabito P, Vidhun R, Zaman A, Rodriguez OJ, Lev EI, Rauch U, Heflt G,Fallon JT, Crandall JP. Blood thrombogenicity in type 2 diabetes mellitus patients is associated with glycemiccontrol. Journal of the American College of Cardiology 2001; 38:1307-1312.


Perassolo MS, Moulin CC, Almeida JC, Camargo JL, Pra RL, Zelmanovitz T, Mello VD, Azevedo MJ, Maia AL, GrossJL. Fatty acid composition of serum lipid fractions in type 2 diabetic patients with microalbuminuria. DiabetesCare 2003; 26:613-618.

Rizkalla SW, Boillot J, Taghrid L, Rigoir A, Laromiguiere M, Elgrably F, Huet D, Slama G. Improved plasmaglucose control, whole-body glucose utilization, and lipid profile on a low-glycemic index diet in type 2 diabeticmen: a randomized controlled trial. Diabetes Care 2004; 27:1866-1872.

Rodriguez-Villar C, Perez-Heras A, Mercade I, Casals E, Ros E. Comparison of a high-carbohydrate and ahigh-monounsaturated fat, olive oil-rich diet on the susceptibility of LDL to oxidative modification in subjects withtype 2 diabetes mellitus. Diabetic Medicine 2004; 21:142-149.

Storm H, Thomsen C, Pedersen E, Rasmussen O, Christiansen C, Hermansen K. Comparison of a carbohydrate-richdiet and diets rich in stearic or palmitic acid in NIDDM patients. Diabetes Care 1997; 20:1807-1813.

Tapsell LC, Owen A, Gillen LJ, Bare M, Patch CS, Kennedy M, Betterham M. Including walnuts in alow-fat/modified-fat diet improves HDL cholesterol-to-total cholesterol ratios in patients with type 2 diabetes. Diabetes Care 2004; 27:2777-2783.

Vedovato M, Lepore G, Coracina A, Dodesini AR, Jori E, Tiengo A, Del Prato S, Trevisan R. Effect of sodium intakeon blood pressure and albuminuria in Type 2 diabetic patients: the role of insulin resistance. Diabetologia 2004;47:300-303.

West SG, Hecker KD, Mustad VA, Nicholson S, Schoemer SL, Wagner P, Hinderliter AL, Ulbrecht J, Ruey P,Kris-Etherton PM. Acute effects of monosaturated fatty acids with and without omega-3 fatty acids on vasularreactivity in individuals with type 2 diabetes. Diabetologia 2005; 48: 113-122.

Yu-Poth S, Zhao G, Etherton T, Naglak M, Jonnalagadda S, Kris-Etherton PM. Effects of the National CholesterolEducation Program’s Step I and Step II dietary intervention programs on cardiovascular disease risk factors: ameta-analysis. Am J Clin Nutr. 1999;69:632-646.


Quick Links

Recommendations SummaryDM: Weight Management 2008


Recommendation(s) DM: Diabetes and Weight Management

The RD should advise that glycemic control is the primary focus for diabetes management. While decreasing energyintake may improve glycemic control, it is unclear whether weight loss alone will improve glycemic control. Sustainedweight loss interventions lasting 1 year or longer reported inconsistent effects on hemoglobin A1C.



None.


Recommendations apply to persons with diabetes who are overweight or obese.


Although costs of MNT sessions and reimbursement vary, medical nutrition therapy sessions are essential forimproved outcomes.


improved outcomes.


In randomized clinical trials, approximately half report improvement in A1C values with weight loss;whereas, approximately half report no improvement in A1C values despite fairly similar weight losses. Eleven studies with more than 1 diet arm (Hollander et al, 1998; Manning et al, 1998; Hanefeld et al,2002; Miles et al, 2002; Kelley et al, 2003; Redmon et al, 2003; Brinkworth et al, 2004; Metz et al,2004; Wolf et al, 2004; Li et al, 2005; Berne et al, 2005; Redmon et al, 2005) reported weight loss andA1C values at 12 months. Six studies in diet arms reported no improvement in A1C (Hollander et al, 1998; Manning et al, 1998;Redmon et al, 2003; Brinkworth et al, 2004; Wolf et al, 2004; Li et al, 2005; Redmon et al, 2005)despite weight loss (range: -0.8 to -4.4 kg) in all but one study which reported no weight loss (Manninget al, 1998). Five studies in diet arms reported improvement in A1C ranging from -0.2% to -0.6% (Hanefeld et al,2002; Miles et al, 2002; Kelley et al, 2003; Mertz et al, 2004; Berne et al, 2005) with fairly similar weightlosses (range: -1.3 to -5.1 kg).Studies using weight loss medications (orlistat and lifestyle, sibutramine) report consistent improvementin A1C. Six studies with an orlistat arm (Hollander et al, 1998; Hanefeld et al, 2002; Miles et al, 2002;Kelley et al, 2003; Derosa et al, 2004; Berne et al, 2005) reported improvements in A1C values (range:-0.3% to -1.1%) with orlistat and lifestyle intervention with weight loss (range: -3.9 to -6.2 kg). Four studies (McNulty et al, 2003; Redmon et al, 2003; Derosa et al, 2004; Sanchez-Reyes et al, 2004;Redmon et al, 2005) reported improvements in A1C values (range: -0.3% to -6.0%) with sibutraminewith weight loss (range: -4.1 to -8.0 kg).Ten studies reported significant improvements in at least one lipid value, generally in triglycerides and HDLcholesterol from weight loss either by diet alone or with weight loss medications (Hollander et al, 1998;Hanefeld et al, 2002; Miles et al, 2002; Paisey et al, 2002; Ash et al, 2003; Kelley et al, 2003; McNulty etal, 2003; Metz et al, 2004; Berne et al, 2005; Li et al, 2005). Six studies reported improvement in blood pressure with weight loss (Miles et al, 2002; Redmon et al,2003; Brinkworth et al, 2004; Derosa et al, 2004; Metz et al, 2004; Li et al, 2005; Redmon et al, 2005);however, one study using sibutramine reported increases in blood pressure (McNulty et al, 2003) and onestudy using sibutramine reported no change in blood pressure (Derosa et al, 2004).


Conclusion statement is Grade II.

Minority Opinions

Consensus reached.


What is the long-term effect (1 year or greater) of weight management on metabolic outcomes in persons with type 1and type 2 diabetes?


Berne C, for the Orlistat Swedish Type 2 Diabetes Study Group. A randomized study of orlistat in combinationwith a weight management programme in obese patients with Type 2 diabetes treated with metformin. DiabeticMedicine 2005;22: 612-618.

Brinkworth GD, Noakes M, Parker B, Foster P, Clifton PM. Long-term effects of advice to consume a high-protein,low-fat diet, rather than a conventional weight-loss diet, in obese adults with Type 2 diabetes: one-year follow-upof a randomized trial. Diabetologia 2004; 47:1677-1686.

Brown SA, Upchurch S, Anding R, Winter M, Ramirez G. Promoting weight loss in type 2 diabetes. Diabetes Care.1996;19(6):613-624.

Derosa G, Cicero AF, Murdolo G, Ciccarelli L, Fogari R. Comparison of metabolic effects of orlistat and sibutraminetreatment in Type 2 diabetic obese patients. Diabetes Nutr Metab 2004;17:222-229.

Hanefeld M, Sachse G. The effects of orlistat on body weight and glycaemic control in overweight patients withtype 2 diabetes: a randomized, placebo-controlled trial. Diabetes, Obesity and Metabolism 2002; 4:415-423.

Hollander PA, Elbein SC, Hirsch IB, Kelley D, McGill J, Taylor T, Weiss SR, Crockett SE, Kaplan RA, Comstock J,Lucas CP, Lodewick PA, Canovatchel W, Chung J, Hauptman J. Role of orlistat in the treatment of obese patientswith type 2 diabetes. Diabetes Care. 1998;21:1288-1294.

Kelley DE, Bray GA, Pi-Sunyer FX, Klein S, Hill J, Miles J, Hollander P. Clinical efficacy of orlistat therapy inoverweight and obese patients with insulin-treated type 2 diabetes: a 1-year randomized controlled trial .Diabetes Care 2002;25:1033-1041.

Li Z, Hong K, Saltsman P, DeShields S, Bellman M, Thames G, Liu Y, Wang H-J, Elashoff R, Heber D. Long-termefficacy of soy-based meal replacements vs an individualized diet plan in obese type II DM patients: relativeeffects on weight loss, metabolic parameters, and C-reactive protein. Eur J Clin Nutr 2005;59:411-418


Manning RM, Jung RT, Leese GP, Newton RW. The Comparison of Four Weight Reduction Strategies Aimed atOverweight Patients with Diabetes Mellitus: Four-year Follow-up. Diabetic Medicine 1998;15:497-502.

Mayer-Davis EJ, D'Antonio AM, Smith SM, Kirkner G, Martin SL, Parra-Medina D, Schultz R. Pounds off withEmpowerment (POWER): a clinical trial of weight management strategies for black and white adults with diabeteswho live in medically underserved rural communities. Am J Public Health. 2004;94:1736-1742.

McNulty SJ, Ur E, Williams G; for the Multicenter Sibutramine Study Group. A randomized trial of sibutramine inthe management of obese type 2 diabetic patients treated with metformin. Diabetes Care. 2003; 125-131.

Metz JA, Stern JS, Kris-Etherton P, Reusser ME, Morris CD, Hatton DC, Oparil S, Haynes RB, Resnick LM,Pi-Sunyer FX, Clark S, Chester L, McMahon M, Snyder GW, McCarron DA. A randomized trial of improved weightloss with a prepared meal plan in overweight and obese patients: impact on cardiovascular risk reduction. ArchIntern Med. 2000; 160: 2,150-2,158.

Miles JM, Leiter L, Hollander P, Wadden T, Anderson JW, Doyle M, Foreyt J, Aronne L and Klein S. Effect of orlistatin overweight and obese patients with type 2 diabetes treated with metformin. Diabetes Care2002;25(7):1123-1128.

Norris SL, Zhang X, Avenell A, Gregg E, Bowman B, Serdula M, Brown TJ, Schmid CH and Lau J. Long-termeffectiveness of lifestyle and behavioral weight loss interventions in adults with type 2 diabetes: a meta-analysis.Am J Med 2004 Nov 15;117(10):762-74.

Paisey RB, Frost J, Harvey P, Paisey A, Bower L, Paisey RM, Taylor P, Belka I. Five-year results of a prospectivevery low calorie diet or conventional weight loss programme in type 2 diabetes. J Hum Nutr Diet2002;15(2):121-7.

Redmon JB, Raatz SK, Reck KP, Swanson JE, Kwong CA, Fan Q, Thomas W and Bantle JP. One-year outcome of acombination of weight loss therapies for subjects with type 2 diabetes: a randomized trial. Diabetes Care2003;26(9):2505-2511.

Redmon JB, Reck KP, Raatz SK, Swanson JE, Kwong CA, Ji H, Thomas W, Bantle JP. Two-year outcome of acombination of weight loss therapies for Type 2 diabetes. Diabetes Care 2005;28:1311-1315.

Sanchez-Reyes L, Fanghanel G, Yamamoto J, Martinez-Rivas L, Campos-Franco E, Berber A. Use of sibutramine inoverweight adult Hispanic patients with type 2 diabetes mellitus: A 12-month, randomized, double-blindplacebo-controlled clinical trial. Clinical Therapeutics. 2004; 26(9):1,427-1,435.

Vettor R, Serra R, Fabris R, Pagano C and Federspil G. Effect of sibutramine on weight management andmetabolic control in type 2 diabetes: A meta-analysis of clinical studies. Diabetes Care. 2005; 28(4): 942-949.

Wing RR, Koeske R, Epstein LH, Nowalk MP, Gooding W, Becker D. Long-term effects of modest weight-loss intype II diabetic patients. Arch Intern Med. 1987;147:1749-1753.



Also see American Dietetic Association Adult Weight Management Evidence-Based Nutrition Practice Guideline.


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Recommendations SummaryDM: Physical Activity 2008


Recommendation(s) DM: Type 2 Diabetes and Physical Activity

In persons with type 2 diabetes, 90 to 150 minutes of accumulated moderate-intensity aerobic physical activity perweek as well as resistance/strength training three times per week is recommended. Both aerobic and resistance trainingimprove glycemic control, independent of weight loss. Physical activity also improves insulin sensitivity and decreases riskfor cardiovascular disease and all-cause mortality.


DM: Type 1 Diabetes and Physical Activity

Individuals with type 1 diabetes should be encouraged to engage in regular physical activity. Although exercise is not


http://www.adaevidencelibrary.com/topic.cfm?cat=2798

Individuals with type 1 diabetes should be encouraged to engage in regular physical activity. Although exercise is notreported to improve glycemic control in persons with type 1 diabetes, individuals may receive the same benefits fromexercise as the general public—decreased risk for cardiovascular disease and improved sense of well-being.


DM: Physical Activity and Insulin/Insulin Secretagogue Use

The RD should instruct individuals on insulin or insulin secretagogues on the safety guidelines to prevent hypoglycemia(frequent blood glucose monitoring and possible adjustment in insulin dose or carbohydrate intake). Research indicatesthat the incidence of hypoglycemia during exercise may depend on baseline glucose levels.



Before beginning a program of physical activity more vigorous than brisk walking, people with diabetesshould be assessed for conditions that might be associated with an increased risk of cardiovasculardisease. Of concern are uncontrolled hypertension, severe autonomic or peripheral neuropathy, andpreproliferative or proliferative retinopathy or macular edema.In previously sedentary individuals whose 10-year risk of a coronary event is likely to be equal to orgreater than 10 percent, a graded exercise test with electrocardiogram (ECG) monitoring is recommended.In individuals taking insulin or insulin secretagogues, physical activity can cause hypoglycemia ifmedication dose or carbohydrate intake is not adjusted. Carbohydrate should be ingested if preexerciselevels are less than 100 mg/dl.


This recommendation applies to persons with type 1 or type 2 diabetes, and persons with type 1 or type 2diabetes on insulin or insulin secretagogues.


In previously sedentary individuals, a graded exercise test with electrocardiogram (ECG) monitoring isrecommended before undertaking aerobic physical activity with intensity exceeding the demands of everyday living (more intense than brisk walking), and this is a potential cost.


In people with type 2 diabetes, 90 - 150 minutes of weekly physical activity (both aerobic exercise andresistance/strength training) reduces A1C (Boule et al, 2001; Castaneda et al, 2002; Dunstan et al, 2002;Goldhaber-Fiebert et al, 2003; Kirk et al, 2003; Kirk et al, 2004; Sigal et al, 2004; Van Rooijen et al,2004; Cauza et al, 2005; Di Loreto et al, 2005), improves insulin sensitivity (Mayer-Davis et al, 1998;Cauza et al, 2005), and decreases relative risk for all-cause mortality (Wei et al, 2000; Church et al, 2004). In persons with type 1 diabetes, the incidence of hypoglycemia during exercise depends on baselineglucose levels, and exercise often results in overnight hypoglycemia (Tsalikian et al, 2005; Tansey et al,2006). Glycemic control generally does not improve in response to ongoing participation in physical activity alone(Roberts et al, 2002; Sarnblad et al, 2005). One study reported possible gender differences in A1C (Waden et al, 2005).American Diabetes Recommendation: To improve glycemic control, assist with weight maintenance, andreduce risk of CVD, at least 150 minutes/week of moderate-intensity aerobic physical activity (50-70% ofmaximum heart rate) and/or at least 90 minutes/week of vigorous aerobic exercise (>70% of maximumheart rate) is recommended. The physical activity should be distributed over at least 3 days/week andwith no more than two consecutive days without physical activity (Grade A).American Diabetes Recommendation: In the absence of contraindications, people with type 2 diabetesshould be encouraged to perform resistance exercise three times a week, targeting all major musclegroups, progressing to three sets of 8-10 repetitions at a weight that cannot be lifted more than 8-10times (Grade A).


Conclusion statements received Grades I and II

Minority Opinions

Consensus reached.


What is the effect of physical activity (for at least 3 months) combined with MNT on metabolic outcomes in persons withtype 2 diabetes?

What is the effect of physical activity combined with Medical Nutrition Therapy (MNT) on metabolic outcomes in personswith type 1 diabetes?


References Boule NG, Haddad E, Kenny GP, Wells GA, Sigal RJ. Effects of exercise on glycemic control and body mass in type2 diabetes mellitus. A meta-analysis of controlled clinical trials. JAMA. 2001;286:1218-1227.

Castaneda C, Layne JE, Munoz-Orians L, Gordon PL, Walsmith J, Foldvari M, Roubenoff R, Tucker KL, Nelson ME. A randomized controlled trial of resistance exercise training to improve glycemic control in older adults with type 2diabetes. Diabetes Care 2002; 25(12): 2335-2341.

Cauza E, Hanusch-Enserer U, Strasser B, Ludvik B, Metz-Schimmerl S, Pacini G, Wagner O, Georg P, Prager R,Kostner K, Dunky A, Haber P. The relative benefits of endurance and strength training on the metabolic factorsand muscle function of people with type 2 diabetes mellitus. Arch Phys Med Rehabil 2005; 86:1527-1533.

Church TS, Cheng YJ, Earnest CP, Barlow CE, Gibbons LW, Priest EL, Blair SN. Exercise capacity and bodycomposition as predictors of mortality among men with diabetes. Diabetes Care 2004; 27:83-88.

Clark M, Hampson SE, Avery L, Simpson R. Effects of a tailored lifestyle self-management intervention in patientswith Type 2 diabetes. British Journal of Health Psychology 2004; 9: 365-379.

Di Loreto C, Ranchelli A, Fanelli C, Fatone C, Lucidi P, Taglioni C, Murdolo G, Santeusanio F, De Cicco A, De Feo F,Parlanti N. Make your diabetic patients walk: long-term impact of different amounts of physical activity on type 2diabetes. Diabetes Care 2005; 28:1295-1302.

Dunstan DW, De Courten M, Daly RM, Shaw J, Owen N, Zimmet P, Jolley D. High-intensity resistance trainingimproves glycemic control in older patients with type 2 diabetes. Diabetes Care 2002;25:1729-1736.

Dunstan DW, Daly RM, Owen N, Jolley D, Vulikh E, Shaw J, Zimmet P. Home-based resistance training is notsufficient to maintain improved glycemic control following supervised training in older individuals with type 2diabetes. Diabetes Care 2005: 28:3-9.


Kirk A, MacIntyre P, Mutrie N, Fisher M. Increasing physical activity in people with type 2 diabetes. Diabetes Care2003;26:1186-1192.

Kirk A, Mutrie N, MacIntyre P, Fisher M. Effects of a 12-month physical activity counseling intervention onglycemic control and on the the status of cardiovascular risk factors in people with Type 2 diabetes. Diabetologia 2004;47:821-832.

Mayer-Davis EJ, D'Agostino R, Karter AJ, Haffner SM, Rewers MJ, Saad M, Bergman RN. Intensity and amount ofphysical activity in relation to insulin sensitivity. The Insulin Resistance and Atherosclerosis Study (IRAS). JAMA.1998;279:669-674.

Sigal RJ, Kenny GP, Wasserman DH, Castaneda-Sceppa C. Physical activity/exercise and type 2 diabetes. Diabetes Care 2004; 27(10):2518-2539.

Van Rooijen AJ, Rheeder P, Eales CJ, Becker PJ. Effect of exercise versus relaxation on haemoglobin A1C in Blackfemales with type 2 diabetes mellitus. QJ Med 2004: 97:343-351.

Wei M, Gibbons LW, Kampert JB, Nichaman MZ, Blair SN. Low cardiorespiratory fitness and physical inactivity inmen with type 2 diabetes. Annals of Intern Med 2000;132:605-611.

Roberts L, Jones TW, Fournier PA. Exercise training and glycemic control in adolescents with poorly controlledtype 1 diabetes mellitus. J Pediatr Endocrinol Metab 2002;15(5):621-7.

Sarnblad S, Ekelund U, Aman J. Physical activity and energy intake in adolescent girls with Type 1 diabetes. Diabet Med 2005;22(7):893-9.

Tansey MJ, Tsalikian E, Beck RW, Mauras N, Buckingham BA, Weinzimer SA, Janz KF, Kollman C, Xing D, RuedyKJ, Steffes MW, Borland TM, Singh RJ, Tamborlane WV, The Diabetes Research in Children Network (DirecNet)Study Group. The effects of aerobic exercise on glucose and counterregulatory hormone concentrations inchildren with type 1 diabetes. Diabetes Care 2006;29(1):20-5.

Tsalikian E, Mauras N, Beck RW, Tamborlane WV, Janz KF, Chase HP, Wysocki T, Weinzimer SA, Buckingham BA,Kollman C, Xing D, Ruedy KJ; Diabetes Research in Children Network Direcnet Study Group. Impact of exerciseon overnight glycemic control in children with type 1 diabetes mellitus. J Pediatr 2005;147(4):528-34.

Waden J, Tikkanen H, Forsblom C, Fagerudd J, Pettersson-Fernholm K, Lakka T, Riska M, Groop PH, FinnDianeStudy Group. Leisure time physical activity is associated with poor glycemic control in type 1 diabetic women: the FinnDiane study. Diabetes Care 2005;28(4):777-82.



American Diabetes Association. Standards of medical care in diabetes - 2007. Diabetes Care 2007;30 Suppl1:S4-41.




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Recommendations SummaryDM: Coordination of Care and Diabetes 2008


Recommendation(s) DM: Coordination of Care

The RD should implement MNT and coordinate care with an interdisciplinary team. An interdisciplinary team approach isnecessary to integrate MNT for patients with diabetes into overall management.

Rating: ConsensusImperative


None.


None.




MNT has its greatest impact at diagnosis of diabetes (Monk et al, 1995; Delahanty et al, 1998).Eight studies (Franz et al, 1995; DAFNE Study Group, 2002; Graber et al, 2002; Miller et al, 2002;Goldhaber-Fiebert et al, 2003; Wilson et al, 2003; Lemon et al, 2004; Gaetke et al, 2006), evaluating theeffectiveness of diabetes MNT at three to six months, reported reductions in A1C, ranging from 0.25% to2.9%, depending on the type and duration of diabetes. Individual sessions ranging from one to five or aseries of 10 to 12 group sessions were employed.A variety of nutrition therapy interventions, such as a reduced energy and fat intake, carbohydratecounting, simplified meal plans, healthy food choices, individualized meal planning strategies, exchangelists, insulin-to-carbohydrate ratios and behavioral strategies were implemented.The number of initial and follow-up sessions varies in all the studies.Studies reporting on effectiveness of MNT from six to twelve months (Lemon et al, 2004; DAFNE StudyGroup, 2002; Franz et al, 1995; Wolf et al, 2004; Banister et al, 2004; Chima et al, 2005; Bray et al,2005) report a variety in the number and type of MNT sessions that lead to improved outcomes.Therefore, the RD needs to determine what is appropriate for individual clients.Seven studies (DCCT, 1993; Laitinen et al, 1993; Maislos et al, 2002; Banister et al, 2004; Wolf et al,2004; Bray et al, 2005; Chima et al, 2005) report sustained improvements in A1C at 12 months andlonger. All involved regular sessions with an RD, ranging from monthly to three sessions per year.Seven studies (DCCT, 1993; Franz et al, 1995; Goldhaber-Fieber et al, 2003; Banister et al, 2004; Lemonet al, 2004; Wolf et al, 2004; Gaetke et al, 2006) report improvements in other outcomes, such asimproved lipid profiles, weight management, decreased need for medications and reduced risk for onsetand progression of comorbidities.American Diabetes Association Recommendation: An interdisciplinary team approach is necessary tointegrate MNT for patients with diabetes into overall management (Grade E).American Diabetes Association Recommendation: Establishing an interdisciplinary team, implementationof MNT, and timely diabetes-specific discharge planning improves the care of patients with diabetes duringand after hospitalizations (Grade E).



Minority Opinions

Consensus reached.



References
























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Recommendations SummaryDM: Monitor & Evaluate and Diabetes 2008



Recommendation(s) DM: Monitoring and Evaluation

The RD should monitor and evaluate food intake, medication, metabolic control (glycemia, lipids, and blood pressure),anthropometric measurements and physical activity. Research reports sustained improvements in A1C at 12 months andlonger with long-term follow-up encounters with an RD.


DM: Evaluation of Glycemic Control

The RD should primarily use blood glucose monitoring results in evaluating the achievement of goals and effectiveness of MNT. Glucose monitoring results can be used to determine whether adjustments in foods and meals will be sufficient toachieve blood glucose goals or if medication additions or adjustments need to be combined with MNT.

Rating: ConsensusImperative


None.


None.




MNT has its greatest impact at diagnosis of diabetes (Monk et al, 1995; Delahanty et al, 1998).Eight studies (Franz et al, 1995; DAFNE Study Group, 2002; Graber et al, 2002; Miller et al, 2002;Goldhaber-Fiebert et al, 2003; Wilson et al, 2003; Lemon et al, 2004; Gaetke et al, 2006), evaluating theeffectiveness of diabetes MNT at three to six months, reported reductions in A1C, ranging from 0.25% to2.9%, depending on the type and duration of diabetes. Individual sessions ranging from one to five or aseries of 10 to 12 group sessions were employed.A variety of nutrition therapy interventions, such as a reduced energy and fat intake, carbohydratecounting, simplified meal plans, healthy food choices, individualized meal planning strategies, exchangelists, insulin-to-carbohydrate ratios and behavioral strategies were implemented.The number of initial and follow-up sessions varies in all the studies.Studies reporting on effectiveness of MNT from six to twelve months (Lemon et al, 2004; DAFNE StudyGroup, 2002; Franz et al, 1995; Wolf et al, 2004; Banister et al, 2004; Chima et al, 2005; Bray et al,2005) report a variety in the number and type of MNT sessions that lead to improved outcomes.Therefore, the RD needs to determine what is appropriate for individual clients.Seven studies (DCCT, 1993; Laitinen et al, 1993; Maislos et al, 2002; Banister et al, 2004; Wolf et al,2004; Bray et al, 2005; Chima et al, 2005) report sustained improvements in A1C at 12 months andlonger. All involved regular sessions with an RD, ranging from monthly to three sessions per year.Seven studies (DCCT, 1993; Franz et al, 1995; Goldhaber-Fieber et al, 2003; Banister et al, 2004; Lemonet al, 2004; Wolf et al, 2004; Gaetke et al, 2006) report improvements in other outcomes, such asimproved lipid profiles, weight management, decreased need for medications and reduced risk for onsetand progression of comorbidities.American Diabetes Association Recommendation: Plasma glucose monitoring can be used to determinewhether adjustments in foods and meals will be sufficient to achieve blood glucose goals or ifmedication(s) needs to be combined with MNT (Grade E).


Conclusion Statement for MNT given Grade I

Minority Opinions

Consensus reached.



References


Ash S, Reeves MM, Yeo S, Morrison G, Carey D, Capra S. Effect of intensive dietetic interventions on weight andglycaemic control in overweight men with Type II diabetes: a randomised trial. International Journal of Obesity.2003; 27:797-802.






















Documents

Diabetes Type 1 and 2 · Lemon CC, Lacey K, Lohse B, Hubacher DO, Klawitter B, Palta M. Outcomes monitoring of health, behavior, and quality of life after nutrition intervention in