International Textbook of Diabetes Mellitus

R. A. DeFronzo, E. Ferrannini, Paul Zimmet, George Alberti, R. A. DeFronzo, E. Ferrannini, Paul Zimmet, George Alberti

• Publisher: Wiley-Blackwell
• Year: 2015
• ISBN:
  9781118387672
• Edition: 4
• Topic: Medicine
• Subtopic: Endocrinology & Metabolism

The International Textbook of Diabetes Mellitus has been a successful, well-respected medical textbook for almost 20 years, over 3 editions. Encyclopaedic and international in scope, the textbook covers all aspects of diabetes ensuring a truly multidisciplinary and global approach. Sections covered include epidemiology, diagnosis, pathogenesis, management and complications of diabetes and public health issues worldwide. It incorporates a vast amount of new data regarding the scientific understanding and clinical management of this disease, with each new edition always reflecting the substantial advances in the field. Whereas other diabetes textbooks are primarily clinical with less focus on the basic science behind diabetes, ITDM's primary philosophy has always been to comprehensively cover the basic science of metabolism, linking this closely to the pathophysiology and clinical aspects of the disease.

Edited by four world-famous diabetes specialists, the book is divided into 13 sections, each section edited by a section editor of major international prominence. As well as covering all aspects of diabetes, from epidemiology and pathophysiology to the management of the condition and the complications that arise, this fourth edition also includestwo new sections on NAFLD, NASH and non-traditional associations with diabetes, and clinical trial evidence in diabetes.

This fourth edition of an internationally recognised textbook will once again provide all those involved in diabetes research and development, as well as diabetes specialists with the most comprehensive scientific reference book on diabetes available.

Section VIII

Management of diabetes: diet, exercise and drugs

Chapter 40
Dietary management of diabetes mellitus in Europe and North America

Jim I. Mann^1,2 and Alexandra Chisholm¹

¹Department of Human Nutrition, University of Otago, Dunedin, New Zealand

²Obesity Research Centre, University of Otago, Dunedin, New Zealand

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Key points

• Dietary management is a cornerstone of treatment for patients with type 1 and type 2 diabetes (T1DM, T2DM). Benefits are derived principally from naturally occurring foods rather than supplements or functional foods.
• In order to achieve compliance with dietary advice, specific goals should be individually negotiated with the patient. Whenever possible such advice should be given by a counselor specifically trained in nutrition management of diabetes and associated comorbidities.
• For patients with T1DM who are not overweight, basing dose of rapidly acting insulin on carbohydrate content of meals and snacks (carbohydrate counting) as well as preprandial glucose levels, may be expected to improve overall glycemic control.
• For those with T2DM who are overweight, controlling energy intake to achieve weight reduction is likely to improve glycemic control to the extent that will obviate or delay the need for oral agents or insulin. If already on drug therapy, intensified dietary treatment may be expected to produce further improvement in glycemic control and often dose reduction. Cardiovascular risk factors also improve.
• All people with diabetes should aim to achieve intakes of saturated and trans unsaturated fatty acids which are well below 10% total energy and dietary salt to below 6 g d⁻¹ to reduce cardiovascular risk.
• A wide range of intakes of carbohydrate (45–60% total energy), cis monunsaturated fatty acids (10–20% TE), and protein (10–20% TE), are acceptable and will depend upon personal preference, extent and nature of metabolic derangement and degree of adiposity. However, carbohydrates should be derived principally from a range of vegetables, fruits, legumes, and wholegrains which are rich in dietary fiber and have a low glycemic index.
• Polyunsaturated fatty acids may be increased from current low levels to a maximum of 10% TE and should be derived from sources of both n-3 and n-6 fatty acids.
• The wide range of acceptable intakes enables compatibility with the many different dietary patterns of Europe and North America.

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Introduction

Dietary modification is the mainstay of treatment for type 2 diabetes (T2DM). Despite the usually progressive nature of the disease, many newly diagnosed patients with T2DM who comply with dietary advice will show improvement in glycemic control to an extent that will obviate or delay the need for oral agents and insulin. For those who require drug therapy, attention to dietary advice can be expected to further improve glycemic control [1]. In type 1 diabetes (T1DM) dietary advice aims to minimize excessive postprandial glycemia and fluctuations in blood glucose levels. Avoidance of hypoglycemia is a particularly important aim. In all people with diabetes, nutrition therapy is also designed to reduce the risk of long-term complications both by improving glycemic control and by reducing other risk factors (notably dyslipidemia and raised blood pressure levels) for vascular disease. Dietary advice in relation to choices about types of foods for those with T2DM and T1DM is similar, and the major principles resemble those for entire populations at high risk of CHD. There is therefore no need for diabetic patients to be given meals that differ from those eaten by the rest of the family. Dietary recommendations for people with diabetes have been made in many countries. It is reassuring that those of the Diabetes and Nutrition Study Group of the European Association for the Study of Diabetes (DNSG), representing the majority of European countries [2] and the American Diabetes Association (ADA) [3] are generally consistent. These two organizations were amongst the first to issue evidence-based guidelines for the nutritional management of people with diabetes. Any points of difference between the two sets of recommendations are indicated in the text below. Table 40.1 summarizes the basic principles of diabetic dietary recommendations.

Table 40.1 Key aspects of the current recommendations for diabetic diet and lifestyle

Dietary energy and body weight	Achieve and/or maintain BMI of 18.5–25 kg m^−2 or if obese, a reduction of at least 5% starting weight
	Diet and exercise important
Dietary fat	Saturated plus trans unsaturated fatty acids: < well below 10% total energy
	Polyunsaturated fatty acids: 6–10% total energy
	Monounsaturated fatty acids: 10–20% total energy
	Total fat: <35% total energy (if overweight <30%)
	Oily fish, soybean and rapeseed oil, nuts and green leafy vegetables to provide n-3 fatty acids
	Cholesterol: <200 g d^−1
Carbohydrate	Total carbohydrate: 45–60% total energy, influenced by metabolic characteristics
	Vegetables, fruits, legumes, and cereal-derived foods preferred
Dietary fiber and glycemic index	Naturally occurring foods rich in dietary fiber are encouraged
	Ideally dietary fiber intake should be more than 40 g d^−1 (or 20 g/1000 kcal d^−1), half-soluble (lesser amounts also beneficial)
	Five servings per day of fiber-rich vegetables and fruit and four or more servings of legumes per week help to provide minimum requirements
	Cereal-based foods should be wholegrain and high in fiber
	Carbohydrate-rich low-glycemic-index foods are suitable choices, provided other attributes are appropriate
Sucrose and other free sugars	If desired and blood glucose levels are satisfactory, free sugars up to 50 g d^−1 may be incorporated into the diet
	Total free sugars should not exceed 10% total energy (less for those who are overweight)
Protein and renal disease	Total protein intake at lower end of normal range (0.8 g kg^−1 d^−1) for type 1 patients with established nephropathy
	For all others, protein should provide 10–20% total energy
Vitamins, antioxidant nutrients, minerals, and trace elements	Increase foods rich in tocopherols, carotenoids, vitamin C and flavonoids, trace elements and other vitamins
	Fruits, vegetables, wholegrains rather than supplements recommended
	Restrict salt to less than 6 g d^−1 (less than 2.3 g sodium)
Alcohol	Up to 10 g for women and 20 g for men per day is acceptable for most people with diabetes who choose to drink alcohol
	Special precautions apply to those on insulin or sulfonylureas, those who are overweight and those with hypertriglyceridemia
Special “diabetic” foods, or functional foods and supplements	Nonalcoholic beverages sweetened with non-nutritive sweeteners are useful
	Other special foods not encouraged
	No particular merit of fructose and other “special” nutritive sweeteners over sucrose
Families	Most recommendations suitable for whole family

Source: The 2004 recommendations of the Nutrition Study Group of the European Association for the Study of Diabetes. Mann et al.: Nutrition, Metabolism and Cardiovascular Diseases 2004;14:373–394. Reproduced with permission of Elsevier.

Total energy intake

The majority of people with T2DM are overweight and usually have other features of the metabolic syndrome (raised levels of insulin, raised triglyceride and low high-density lipoprotein (HDL) levels, hypertension, high levels of uric acid, and elevated levels of plasminogen activator inhibitor 1 in addition to hyperglycemia. Even modest weight reduction is associated with a reduction in insulin resis...