Diet in diabetes

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A diabetic diet is a diet that is used by people with diabetes mellitus or high blood sugar to minimize symptoms and dangerous complications of long-term elevations in blood sugar (i.e.: cardiovascular disease, kidney disease, obesity).

Contents

Among guideline recommendations including the American Diabetes Association (ADA) and Diabetes UK, there is no consensus that one specific diet is better than others. [1] [2] This is due to a lack of long term high-quality studies on this subject matter. [1] [2]

For overweight and obese people with diabetes, the most important aspect of any diet is that it results in loss of body fat. [1] [2] Losing body fat has been proven to improve blood glucose control and lower insulin levels. [1] [2]

The most agreed-upon recommendation is for the diet to be low in sugar and refined carbohydrates, while relatively high in dietary fiber, especially soluble fiber. Likewise, people with diabetes may be encouraged to reduce their intake of carbohydrates that have a high glycemic index (GI), although the ADA and Diabetes UK note that further evidence for this recommendation is needed. [3] [4] [1] [2]

Diet composition

General

People with diabetes can eat any food that they want, preferably a healthy diet with some carbohydrates, but they need to be more cognizant of the carbohydrate content of foods and avoid simple sugars like juices and sugar-sweetened beverages. [5] For people dependent on insulin injections (both type 1 and some type 2 diabetics), it is helpful to eat a consistent amount of carbohydrate to make blood sugar management easier. [6]

Macronutrients

To date (2019) there is no consensus that eating a diet consisting of any particular macronutrient composition (i.e.: the ratio of fat, protein, and carbohydrate in the diet) is more beneficial for diabetics. [1] [7] However, research on diabetic diets is limited due to the nature of nutritional research. Studies in this space tend to be observational as opposed to experimental, relatively short in duration and have relatively poor compliance due to the difficulty of controlling the diets of study participants at all hours of the day for extended periods of time. [8] [7] Thus, more large-scale multi-center trials in the future are required to further define recommendations. [8]

Carbohydrates

Carbohydrates include sugars, starches, and fiber. These foods have the greatest impact on blood sugar levels, as once they are consumed they are broken down into sugars that are then absorbed in the small intestine.

The American Diabetes Association (ADA) does not recommend a specific amount of carbohydrate consumption for diabetic diets. [1] Although it is not recommended to use fructose as an added sweetener because it may adversely affect plasma lipids. [9] [10] There is no minimum required amount of daily dietary carbohydrates as the body can make glucose through various metabolic processes including gluconeogenesis and glycogenolysis. [1] The same is not true of the protein and fat as both contain constituent components that are essential and cannot be synthesized through human metabolism.

The ADA also addresses the glycemic index and glycemic load of foods as they pertain to diabetics, but they decline to make specific recommendations due to the unclear clinical utility. [1] However, meta-analyses including the most recent Cochrane Systematic Review have found that a low glycemic index diet results in better blood glucose control as measured by glycated hemoglobin A1c (HbA1c) as well as fewer hypoglycemic episodes. [3] [4]

Fiber

Benefits may be obtained by consumption of dietary fiber. There is some evidence that consuming dietary fiber may help control blood sugar levels; however, the ADA does not recommend any different goals for fiber intake for diabetics compared to non-diabetics. [1]

Fats

The ADA does not make a specific recommendation about the total amount of fat that should be consumed by diabetics on a daily basis. [1] They do note that studies have shown that high fat diets that have replaced carbohydrates with fat have shown improved glycemic control and improved blood lipid profiles (increased HDL concentration and decreased triglycerides) compared to low fat diets. [1] The ADA recommends avoiding all foods that have artificial sources of trans fats but note that the small amount of trans fats that naturally occur in meat and dairy are not a concern. [1]

Cholesterol

As at 2019 the ADA does not have a specific recommendation for dietary cholesterol intake. [1] A causal link between dietary cholesterol consumption and cardiovascular disease has not been established. [1]

Protein

Historically, there has been concern about the level of protein consumption in individuals who have diabetes induced kidney disease; however, there is no evidence that low protein diets improve kidney function. [2] There is no evidence that individuals with diabetes induced kidney disease need to restrict protein intake less than an average person's intake. [2]

Specific diets

Low-carbohydrate diet

For type 1 diabetics, there is a lack of definitive evidence of the usefulness of low-carbohydrate diets due to limited study of this topic. [1] [11] [12] A meta-analysis published in 2018 found only nine papers that had adequately studied the implementation of low carbohydrate diets in type 1 diabetics as of March 2017. [12] This review found that low carbohydrate diets consistently reduced insulin requirements but found inconsistent results in regard to the diet's effect on blood glucose levels. [12] 3 studies found significant decreases in HbA1c on low carbohydrate diets while 5 found that HbA1c levels were stable. [12] This review as well as the ADA consensus statement suggests that low carbohydrate diets may be beneficial for type 1 diabetics but larger clinical trials are needed for further evidence. [1] [12]

A low-carbohydrate diet gives slightly better control of glucose metabolism than a low-fat diet in type 2 diabetes. [13] [14] In a 2019 consensus report on nutrition therapy for adults with diabetes and prediabetes the American Diabetes Association (ADA) states "Reducing overall carbohydrate intake for individuals with diabetes has demonstrated the most evidence for improving glycemia (blood sugar) and may be applied in a variety of eating patterns that meet individual needs and preferences.", it also states that reducing overall carbohydrate intake with low- or very low- carbohydrate eating plans is a viable approach. [15]

The ADA say low-carbohydrate diets can be useful to help people with type 2 diabetes lose weight, but that these diets were poorly defined, difficult to sustain, unsuitable for certain groups of people and that, for diet composition in general". [16] Overall, the ADA recommends people with diabetes develop "healthy eating patterns rather than focusing on individual macronutrients, micronutrients, or single foods". They recommend that carbohydrates in a diet should come from whole food sources such as "vegetables, legumes, fruits, dairy (milk and yogurt), and whole grains"; highly refined foods and sugary drinks should be avoided. [16]

Vegan/vegetarian

An example of a high fiber vegan breakfast Balanced Vegan Breakfast.png
An example of a high fiber vegan breakfast

Although vegan and vegetarian diets can vary greatly in the type of food consumed as well as the macronutrient profile of the diet, they are often lumped together in the context of the scientific literature since they are both considered plant-based diets. Like any other diet's impact on diabetes, the most important factor is the resulting loss of overall fat mass. [1] [2] Both vegan and vegetarian diets have been shown to be beneficial for weight loss in comparison to the standard American diet. [1] [17] For type 2 diabetics, the focus of a vegetarian or vegan diet should be maintaining a level of caloric intake that results in fat loss, adequate protein consumption, adequate consumption of compounds that are most bio-available in animal products (i.e. vitamin B-12, iron, creatine), and whole food carbohydrate sources that are lower in glycemic index.

The Academy of Nutrition and Dietetics maintains that well formulated vegetarian and vegan diets can be healthy and nutritionally adequate for people of all ages. [18] The American Diabetes Association notes that the use of vegetarian or vegan diets for diabetes have had inconclusive results in the literature. [1] Two meta-analyses showed small improvements in HbA1C; whereas, one of the two found that the diets resulted in weight loss and improvement in cardiovascular risk factors. [1]

Low glycemic index diet

Lowering the glycemic index of one's diet may improve the control of diabetes. [19] [20] This includes avoidance of such foods as potatoes cooked in certain ways (i.e.: boiled and mashed potatoes are higher GI than fried) and white bread. [21] Lower glycemic index carbohydrate sources include vegetables, legumes, and whole grains that contain higher fiber content and are digested and absorbed into the blood stream more slowly than refined carbohydrates.

High fiber diet

The ADA recommends a level of fiber intake consistent with the Dietary Guidelines for Americans 2015–2020 (minimum of 14 g of fiber per 1,000 kcal). [1] [22] However, there is some evidence that higher intakes (daily consumption of 50g of fiber and higher), can result in small improvements in blood sugar levels. [23] [24] [25] [26] The ADA cautions that higher intakes may cause digestive issues such as “flatulence, bloating, and diarrhea.” [1]

Timing of meals

For people with diabetes, healthy eating is not simply a matter of what one eats, but also when one eats. For insulin dependent diabetics, when they eat depends on their blood sugar level and the type of insulin they take (i.e.: long-, medium- or quick-acting insulin). If patients check their blood glucose at bedtime and find that it is low, for example below 6 millimoles per liter (108 mg/dL), it is advisable that they take some long-acting carbohydrate before retiring to bed to prevent night-time hypoglycemia.[ citation needed ] Night sweats, headaches, restless sleep, and nightmares can be a sign of nocturnal hypoglycemia, and patients should consult their doctor for adjustments to their insulin routine if they find that this is the case. [27] Another possible sign of nocturnal hypoglycemia is morning hyperglycemia, which actually occurs in response to blood sugar getting too low at night. This is called the Somogyi effect.

In relation to type 2 diabetes, eating most food earlier in the day may be associated with lower levels of overweight and obesity and other factors that reduce the risk of developing type 2 diabetes. [28] The ADA notes that several studies have shown benefit of intermittent fasting on blood sugar control. [1] However, these studies were relatively small and short in duration and further study is warranted. [1] There were also different protocols for fasting which makes comparisons across studies more difficult. [1]

Special diabetes dietary products

Diabetes UK have warned against purchase of products that are specially made for people with diabetes, on grounds that: [29]

NICE (the National Institute for Health and Clinical Excellence in the United Kingdom) advises doctors and other health professionals to "Discourage the use of foods marketed specifically for people with diabetes". [30]

Alcohol

The ADA recommends that people with diabetes limit alcohol consumption as recommended by the Dietary Guidelines for Americans (up to one drink per day for women and up to two drinks per day for men). [1] [22] Consumption of alcohol above this amount may lead to elevations in blood sugar. [1] Consumption of alcohol also puts diabetics at increased risk of hypoglycemia. [1] The ADA states that this may be due to the “inhibition of gluconeogenesis, reduced hypoglycemia awareness due to the cerebral effects of alcohol, and/or impaired counterregulatory responses to hypoglycemia.” [1] This puts diabetics who take insulin or other anti-hyperglycemics at risk of night time or fasting hypoglycemia. [1] Consuming food with alcohol reduces this risk of hypoglycemia. [1]

History

There has been a long history of dietary treatment of diabetes mellitus. Dietary treatment of diabetes mellitus was used in Egypt since 3,500 BC [31] and was used in India by Sushruta and Charaka more than 2000 years ago. [31] In the 18th century, the Scottish surgeon John Rollo argued that calorie restriction could reduce glycosuria in diabetes. [31]

More modern history of the diabetic diet may begin with Frederick Madison Allen and Elliott Joslin, who, in the early 20th century, before insulin was discovered, recommended that people with diabetes eat only a low-calorie and nearly zero-carbohydrate diet to prevent ketoacidosis from killing them. While this approach could extend life by a limited period, patients developed a variety of other medical problems. [32]

The introduction of insulin by Frederick Banting in 1922 allowed patients more flexibility in their eating. [32]

Exchange scheme

In the 1950s, the American Diabetes Association, in conjunction with the U.S. Public Health Service, introduced the "exchange scheme". This allowed people to swap foods of similar nutrition value (e.g., carbohydrate) for another. For example, if wishing to have more than normal carbohydrates for dessert, one could cut back on potatoes in one's first course. The exchange scheme was revised in 1976, 1986, and 1995. [33]

Later developments

Not all diabetes dietitians today recommend the exchange scheme. Instead, they are likely to recommend a typical healthy diet: one high in fiber, with a variety of fruit and vegetables, and low in both sugar and fat, especially saturated fat.

A diet high in plant fibre was recommended by James Anderson. [34] This may be understood as continuation of the work of Denis Burkitt and Hugh Trowell on dietary fibre, [35] which may be understood as a continuation of the work of Price. [36] It is still recommended that people with diabetes consume a diet that is high in dietary fiber.

In 1976, Nathan Pritikin opened a centre where patients were put on programme of diet and exercise (the Pritikin Program). This diet is high on carbohydrates and fibre, with fresh fruit, vegetables, and whole grains. A study at UCLA in 2005 showed that it brought dramatic improvement to a group of people with diabetes or pre-diabetes in three weeks, so that about half no longer met the criteria for the disease. [37] [38] [39] [40]

See also

Related Research Articles

<span class="mw-page-title-main">Carbohydrate</span> Organic compound that consists only of carbon, hydrogen, and oxygen

A carbohydrate is a biomolecule consisting of carbon (C), hydrogen (H) and oxygen (O) atoms, usually with a hydrogen–oxygen atom ratio of 2:1 and thus with the empirical formula Cm(H2O)n, which does not mean the H has covalent bonds with O. However, not all carbohydrates conform to this precise stoichiometric definition, nor are all chemicals that do conform to this definition automatically classified as carbohydrates.

<span class="mw-page-title-main">Hypoglycemia</span> Health condition

Hypoglycemia, also called low blood sugar, is a fall in blood sugar to levels below normal, typically below 70 mg/dL (3.9 mmol/L). Whipple's triad is used to properly identify hypoglycemic episodes. It is defined as blood glucose below 70 mg/dL (3.9 mmol/L), symptoms associated with hypoglycemia, and resolution of symptoms when blood sugar returns to normal. Hypoglycemia may result in headache, tiredness, clumsiness, trouble talking, confusion, fast heart rate, sweating, shakiness, nervousness, hunger, loss of consciousness, seizures, or death. Symptoms typically come on quickly.

The following is a glossary of diabetes which explains terms connected with diabetes.

<span class="mw-page-title-main">Dietary fiber</span> Portion of plant-derived food that cannot be completely digested

Dietary fiber or roughage is the portion of plant-derived food that cannot be completely broken down by human digestive enzymes. Dietary fibers are diverse in chemical composition, and can be grouped generally by their solubility, viscosity, and fermentability, which affect how fibers are processed in the body. Dietary fiber has two main components: soluble fiber and insoluble fiber, which are components of plant-based foods, such as legumes, whole grains and cereals, vegetables, fruits, and nuts or seeds. A diet high in regular fiber consumption is generally associated with supporting health and lowering the risk of several diseases. Dietary fiber consists of non-starch polysaccharides and other plant components such as cellulose, resistant starch, resistant dextrins, inulin, lignins, chitins, pectins, beta-glucans, and oligosaccharides.

<span class="mw-page-title-main">Type 2 diabetes</span> Type of diabetes mellitus with high blood sugar and insulin resistance

Type 2 diabetes (T2D), formerly known as adult-onset diabetes, is a form of diabetes mellitus that is characterized by high blood sugar, insulin resistance, and relative lack of insulin. Common symptoms include increased thirst, frequent urination, fatigue and unexplained weight loss. Symptoms may also include increased hunger, having a sensation of pins and needles, and sores (wounds) that do not heal. Often symptoms come on slowly. Long-term complications from high blood sugar include heart disease, strokes, diabetic retinopathy which can result in blindness, kidney failure, and poor blood flow in the limbs which may lead to amputations. The sudden onset of hyperosmolar hyperglycemic state may occur; however, ketoacidosis is uncommon.

<span class="mw-page-title-main">Glycemic index</span> Number assigned to food

The glycemic (glycaemic) index is a number from 0 to 100 assigned to a food, with pure glucose arbitrarily given the value of 100, which represents the relative rise in the blood glucose level two hours after consuming that food. The GI of a specific food depends primarily on the quantity and type of carbohydrate it contains, but is also affected by the amount of entrapment of the carbohydrate molecules within the food, the fat and protein content of the food, the amount of organic acids in the food, and whether it is cooked and, if so, how it is cooked. GI tables, which list many types of foods and their GIs, are available. A food is considered to have a low GI if it is 55 or less; high GI if 70 or more; and mid-range GI if 56 to 69.

<span class="mw-page-title-main">Low-carbohydrate diet</span> Diets restricting carbohydrate consumption

Low-carbohydrate diets restrict carbohydrate consumption relative to the average diet. Foods high in carbohydrates are limited, and replaced with foods containing a higher percentage of fat and protein, as well as low carbohydrate foods.

The glycemic response to a food or meal is the effect that food or meal has on blood sugar (glucose) levels after consumption. It is normal for blood glucose and insulin levels to rise after eating and then return again to fasting levels over a short period of time. This is particularly so after consumption of meals rich in certain carbohydrates. Glycemic management refers to the selection of foods to manage your blood sugar levels.

The glycemic load (GL) of food is a number that estimates how much the food will raise a person's blood glucose level after it is eaten. One unit of glycemic load approximates the effect of eating one gram of glucose. Glycemic load accounts for how much carbohydrate is in the food and how much each gram of carbohydrate in the food raises blood glucose levels. Glycemic load is based on the glycemic index (GI), and is calculated by multiplying the weight of available carbohydrate in the food (in grams) by the food's glycemic index, and then dividing by 100.

Diabetes is a chronic disease in cats whereby either insufficient insulin response or insulin resistance leads to persistently high blood glucose concentrations. Diabetes affects up to 1 in 230 cats, and may be becoming increasingly common. Diabetes is less common in cats than in dogs. The condition is treatable, and if treated properly the cat can experience a normal life expectancy. In cats with type 2 diabetes, prompt effective treatment may lead to diabetic remission, in which the cat no longer needs injected insulin. Untreated, the condition leads to increasingly weak legs in cats and eventually to malnutrition, ketoacidosis and/or dehydration, and death.

<span class="mw-page-title-main">Hyperinsulinemia</span> Abnormal increase in insulin in the bloodstream relative to glucose

Hyperinsulinemia is a condition in which there are excess levels of insulin circulating in the blood relative to the level of glucose. While it is often mistaken for diabetes or hyperglycaemia, hyperinsulinemia can result from a variety of metabolic diseases and conditions, as well as non-nutritive sugars in the diet. While hyperinsulinemia is often seen in people with early stage type 2 diabetes mellitus, it is not the cause of the condition and is only one symptom of the disease. Type 1 diabetes only occurs when pancreatic beta-cell function is impaired. Hyperinsulinemia can be seen in a variety of conditions including diabetes mellitus type 2, in neonates and in drug-induced hyperinsulinemia. It can also occur in congenital hyperinsulinism, including nesidioblastosis.

<span class="mw-page-title-main">Reactive hypoglycemia</span> Medical condition

Reactive hypoglycemia, postprandial hypoglycemia, or sugar crash is a term describing recurrent episodes of symptomatic hypoglycemia occurring within four hours after a high carbohydrate meal in people with and without diabetes. The term is not necessarily a diagnosis since it requires an evaluation to determine the cause of the hypoglycemia.

The term diabetes includes several different metabolic disorders that all, if left untreated, result in abnormally high concentrations of a sugar called glucose in the blood. Diabetes mellitus type 1 results when the pancreas no longer produces significant amounts of the hormone insulin, usually owing to the autoimmune destruction of the insulin-producing beta cells of the pancreas. Diabetes mellitus type 2, in contrast, is now thought to result from autoimmune attacks on the pancreas and/or insulin resistance. The pancreas of a person with type 2 diabetes may be producing normal or even abnormally large amounts of insulin. Other forms of diabetes mellitus, such as the various forms of maturity-onset diabetes of the young, may represent some combination of insufficient insulin production and insulin resistance. Some degree of insulin resistance may also be present in a person with type 1 diabetes.

<span class="mw-page-title-main">Isomaltulose</span> Chemical compound

Isomaltulose is a disaccharide carbohydrate composed of glucose and fructose. It is naturally present in honey and sugarcane extracts and is also produced industrially from table sugar (sucrose) and used as a sugar alternative.

The Montignac diet is a high-protein low-carbohydrate fad diet that was popular in the 1990s, mainly in Europe. It was invented by Frenchman Michel Montignac (1944–2010), an international executive for the pharmaceutical industry, who, like his father, was overweight in his youth. His method is aimed at people wishing to lose weight efficiently and lastingly, reduce risks of heart failure, and prevent diabetes.

Alpha-glucosidase inhibitors (AGIs) are oral anti-diabetic drugs used for diabetes mellitus type 2 that work by preventing the digestion of carbohydrates. Carbohydrates are normally converted into simple sugars (monosaccharides) by alpha-glucosidase enzymes present on cells lining the intestine, enabling monosaccharides to be absorbed through the intestine. Hence, alpha-glucosidase inhibitors reduce the impact of dietary carbohydrates on blood sugar.

Richard K. Bernstein is a physician and an advocate for a low-carbohydrate diabetes diet to help achieve normal blood sugars for diabetics. Bernstein has type 1 diabetes. His private medical practice in Mamaroneck, New York is devoted solely to treating diabetes and prediabetes.

<span class="mw-page-title-main">Diabetes in dogs</span>

Diabetes mellitus is a disease in which the beta cells of the endocrine pancreas either stop producing insulin or can no longer produce it in enough quantity for the body's needs. The disease can affect humans as well as animals such as dogs.

<span class="mw-page-title-main">Weight management</span> Techniques for maintaining body weight

Weight management refers to behaviors, techniques, and physiological processes that contribute to a person's ability to attain and maintain a healthy weight. Most weight management techniques encompass long-term lifestyle strategies that promote healthy eating and daily physical activity. Moreover, weight management involves developing meaningful ways to track weight over time and to identify ideal body weights for different individuals.

The following outline is provided as an overview of and topical guide to diabetes mellitus :

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  37. ↑ Booth FW, Chakravarthy MV (May 2006). "Physical activity and dietary intervention for chronic diseases: a quick fix after all?". Journal of Applied Physiology. 100 (5): 1439–40. doi:10.1152/japplphysiol.01586.2005. PMID   16614361. S2CID   15566753.
  38. ↑ Roberts CK, Won D, Pruthi S, Kurtovic S, Sindhu RK, Vaziri ND, Barnard RJ (May 2006). "Effect of a short-term diet and exercise intervention on oxidative stress, inflammation, MMP-9, and monocyte chemotactic activity in men with metabolic syndrome factors". Journal of Applied Physiology. 100 (5): 1657–65. doi:10.1152/japplphysiol.01292.2005. PMID   16357066. S2CID   7749445.
  39. ↑ Roberts CK, Barnard RJ (January 2005). "Effects of exercise and diet on chronic disease". Journal of Applied Physiology. 98 (1): 3–30. doi:10.1152/japplphysiol.00852.2004. PMID   15591300. S2CID   3971972.
  40. ↑ Bhattacharya S (13 January 2006). "Three-week diet curbs diabetes". New Scientist .
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