Position Statement

Nutritional Recommendations and Principlesfor Individuals With Diabetes Mellitus: 1986

AMERICAN DIABETES ASSOCIATION

In 1979 the Committee on Food and Nutrition of theAmerican Diabetes Association published a special re-port entitled "Principles of Nutrition and Dietary Rec-ommendations for Individuals With Diabetes Melli-

tus." Publication of the report was prompted by new andemerging information regarding effects of diet on blood glu-cose concentration in diabetic people and by informationrelating aberrations of blood lipid levels, particularly cho-lesterol, with atherosclerosis in the general population. Since1979, much new information has been generated in the fieldof nutrition for management of diabetes. Questions havearisen as to the optimal carbohydrate, protein, and fat intake;the use of fiber; the role of the glycemic index and its relationto food exchanges; and the value of eicosapentanoic acid orfish oil. The 1980s also witnessed a transformation in theapproach to nutrition education. Health care should be pro-vided by a team of professionals, with each member of theteam contributing a particular area of expertise. Ever-growingrecognition of the needs of minority populations has dictatedcloser inspection of these requirements and a need to for-mulate new and more relevant approaches. This report up-dates the original principles and recommendations, based oninformation accumulated since 1979, and the evolving pat-terns of nutritional management. Nutritional recommenda-tions for people with diabetes are similar to those of theAmerican Heart Association, the National Cancer Institute(American Cancer Society), the Nutritional Committee forRecommendations for Children with Diabetes of the Amer-ican Academy of Pediatrics, and the 1985 U.S. DietaryGuidelines.

RECOMMENDATIONS

Calories. Calories should be prescribed to achieve and main-tain a desirable body weight.

Carbohydrate intake.1. The amount of carbohydrates should be liberalized, ide-

ally up to 55-60% of the total calories, and individualized,

with the amount dependent on the impact on blood glucoseand lipid levels and individual eating patterns.

2. Whenever acceptable to the patient, foods containingunrefined carbohydrate/with fiber should be substituted forhighly refined carbohydrates, which are low in fiber.

3. In some individuals, modest amounts of sucrose andother refined sugars may be acceptable, contingent on met-abolic control and body weight.

Protein intake. Americans in general consume too muchprotein. The recommended dietary allowance (RDA) for pro-tein is 0.8 g/kg of body weight for adults. Elderly subjectsmay require more than the RDA. There are circumstanceswhere the protein intake may be reduced, e.g., in patientswith incipient renal disease.

Total fat and cholesterol intake. Total fat and cholesterolintake should be restricted. Total fat should comprise <30%of total calories and cholesterol <300 mg/day. This level ofintake may not be achievable within the context of thenutritional prescription and palatability. If total fat is re-duced, all components should be proportionally reduced. Re-placement of saturated fat with unsaturated fat may slow theprogression of atherosclerosis. The addition of certain fatssuch as eicosapentanoic acid and monounsaturated fats maybe acceptable; however, more research is needed to definetheir value.

Alternative sweeteners. The use of various nutritive andnonnutritive sweeteners is acceptable in the management ofdiabetes.

Salt intake. Many Americans eat more salt (NaCl) thanis necessary. The recommended sodium intake is 1000 mg/1000 kcal not to exceed 3000 mg/day. In hypertensive sub-jects, salt may be harmful, and therefore intake should bereduced. Severe sodium restriction could also be harmful forcertain individuals with poorly controlled diabetes, posturalhypotension, and fluid imbalance.

Alcohol. The same cautions regarding the use of alcoholthat apply to the general public apply to people with diabetes.Specific problems may occur with hypoglycemia, neuropathy,glycemic control, obesity, and/or hyperlipidemia.

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Recommended daily intake (to be tailored to individual needs) METHODS TO ACHIEVE GOALS

Carbohydrate

^60

Protein

(g/kg)

0.8*

PUS

6-8

Fat

S

<10

(%)t

MS

30-(PUS + S)

Cholesterol(mg)

<300

Fiber(g)

40*

'The recommended dietary allowance for protein is 0.8 g/kg body wt foradults. Patients with incipient renal failure may require lower protein in-takes.tlf total fat is reduced, all components, i.e., polyunsaturated (PUS), sat-urated (S), and monounsaturated (MS) fat, should be reduced proportion-ally.$25 g/1000 kcal for people taking low-calorie diets.

Vitamins and minerals. Vitamins and minerals should meetthe recommended requirements for health. There is no evi-dence unique to the patient with diabetes to warrant sup-plementation of vitamin and mineral intake unless the pa-tient is on a very-low-calorie diet or other special circumstancesexist. Calcium supplements may be necessary under specialcircumstances.

GOALS FOR DIABETES MANAGEMENT

1. Restore normal blood glucose and optimal lipid levels.Maintain blood glucose as near to physiologic as possible to1) prevent hyperglycemia and/or hypoglycemia, 2) preventor delay the development of long-term cardiovascular, renal,retinal, neurologic complications associated with diabetesmellitus, 3) contribute to a normal outcome of pregnanciesfor women with diabetes.

2. Maintain normal growth rate in children and adoles-cents as well as the attaining and maintaining reasonablebody weight in adolescents and adults. Any abnormal orunexplained deviation in growth rate or weight gain and/orloss as plotted on standard grids warrants an assessment ofdiabetes control, eating behavior, and caloric intake as wellas consideration of alternative problems and/or diagnosis.

3. Provide adequate nutrition for the pregnant woman,the fetus, and lactation.

4- Stay consistent in the timing of meals and snacks toprevent inordinate swings in blood glucose levels for peopleusing exogenous insulin.

5. Determine a meal plan appropriate for the individual'slife-style and based on a diet history. Blood glucose moni-toring results can then be used to integrate insulin therapywith the usual, as well as unanticipated, eating and exercisepattern.

6. Manage weight for obese people with non-insulin-de-pendent diabetes mellitus (NIDDM). Weight managementinvolves specific changes in food intake and eating behaviorsas well as increased activity level. Continued support andfollow-up by qualified health professionals are important iflong-term life-style changes are to be made.

7. Improve the overall health of people with diabetes throughoptimal nutrition.

The ultimate goal and approach to nutrition education andcounseling is to promote positive behavioral changes. Forthis to occur, a phased plan for nutrition counseling of peoplewith diabetes that aims to achieve more than just educationis important. The key components are listed.

Initial or "survival" phase. In the first stage, a simplified,individualized meal plan and an introduction to the basicsof meal planning are needed.

In-depth and continuing phase. During this phase, the per-son basically learns how to make decisions. Continuing ed-ucation and counseling are needed by everyone with diabetes.All adults should be seen by a nutritionist every 6 mo to 1yr so that subtle changes in life-style can be noted and ap-propriate nutritional changes made. Some people, especiallythose who need to control their weight, may require morefrequent evaluation and counseling.

Children and adolescents with diabetes should be seen bya nutritionist at least every 6 mo, preferably every 3 mo.Nutrition is a changing field, and continuing evaluation andeducation are essential for people with diabetes to incorporatethese changes in their management programs.

Team approach. Whenever possible, a team approach toeducation and counseling should be used that includes theperson with diabetes as an integral member. Family membersand "significant others" also need to be an integral part ofthe education program. A meal-plan prescription and itsimplementation should be planned by the physician and di-etitian in conjunction with other members of the health-care team. A registered dietitian with expertise in diabetesmanagement is the ideal member of the multidisciplinaryteam to provide this education and counseling.

Individualization. It is essential that the meal plan, edu-cation, and counseling program be individualized for theperson with diabetes. With the basic goals of meal planningin mind, the individual's plan needs to be realistic and pro-vide as much flexibility as possible, allowing integration oftherapeutic measures into his/her life-style. Educational toolsthat are appropriate for the individual should be selected,taking into account age and educational level as well as thelevel of existing nutritional knowledge.

Exercise. Regular activity should be encouraged and in-corporated into the daily schedule; aerobic exercise is rec-ommended. Individuals >30 yr old or who have had diabetesfor 5=10 yr should have physician approval to begin an ex-ercise program. For people with insulin-dependent diabetesmellitus (IDDM), the major benefits of exercise are cardio-vascular conditioning, weight maintenance, and lowering oflipid levels. For people with NIDDM, conditioning may alsobe a benefit, but even light exercise can be important ina management program to control blood glucose and lipidlevels.

PRINCIPLES OF GOOD NUTRITION IN DIABETES

Carbohydrates, fiber, and glycemic index. Current evidencesuggests that high-fiber diets, especially of the soluble variety,

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and soluble-fiber supplements offer some improvement incarbohydrate metabolism, lower total cholesterol and low-density lipoprotein (LDL) cholesterol, and have other ben-eficial effects. The insoluble fibers, e.g., wheat bran, maynot have these beneficial effects.

Current estimates of the dietary fiber intake of adults inthe United States range from ~10 to 30 g/day, with menaveraging 19 g/day and women 13 g/day. A practical goalwould be to establish the level of intake and to graduallyincrease it with the goal of doubling the intake for mostindividuals. An intake of up to 40 g of fiber/day or 25 g/1000kcal of food intake appears to be beneficial; in many indi-viduals on weight-reducing diets, higher levels may be un-acceptable because of gastrointestinal side effects. However,the level of maximum benefit has not been determined, buta maximum intake of 50 g seems reasonable.

Fiber supplementation appears to be beneficial only if givenwith a diet comprising at least 50% of the calories as car-bohydrate. Foods should be selected with moderate to highamounts of dietary fiber from a wide variety of foods. Thesefoods include legumes, lentils, roots, tubers, green leafy veg-etables, all types of whole-grain cereals (e.g., wheat, barley,oats, corn, and rye), and fruits. Fruits and vegetables shouldbe eaten raw to maximize the fiber effect, and not pureed,which causes loss or reduction of the fiber effect. The 1986/1987 exchange lists compliled by the American DiabetesAssociation in conjunction with the American Dietetic As-sociation will highlight foods with a high fiber content.

Children may also benefit from an increase in the fibercontent of their diets, but younger children may not toleratelarge amounts of fiber. Pregnant diabetic women appear totolerate fiber well, but there are too few studies to advise foror against its use in pregnancy.

Insufficient data are available on the long-term safety ofhigh-fiber supplements. It is possible that people at risk fordeficiencies, e.g., postmenopausal women, the elderly, orgrowing children, may require supplements of calcium andtrace minerals. People with upper gastrointestinal dysfunc-tion risk bezoar formation and are cautioned against a diethigh in fiber of the leafy vegetable type. Careful attentionmust be paid to insulin dose, because hypoglycemia can resultif there is a radical change in fiber intake and insulin doseis not reduced appropriately. Care must be exercised in theuse of "novel" fibers, e.g., the wood celluloses, because littleis known of their safety and efficacy. Abdominal cramping,discomfort, loose stools, and flatulence can be minimized bystarting with small servings and increasing the portions grad-ually.

Factors other than fiber may result in a food producingrelatively flat blood glucose profiles. These foods may favor-ably influence blood lipids. Classification of foods by theirglycemic effects may facilitate application of this informationin day-to-day management. Currently the consistencies inestimations of the glycemic indices suggest that glycemicindexing of foods may be used, in simplified form, as part ofthe exchange system. There are inconsistencies, however,that suggest this is not the time for general application. A

considerable amount of multifaceted research is required toevaluate the relative value of the glycemic index of foodsversus the exchange system. In the meantime, however, gly-cemic index tables provide a means of identifying the starchyfoods with lower glycemic potential that may be offered ontrial to people with diabetes. The text of the exchange-listbooklet has been rewritten to make it more useful in theeducation of people with diabetes and will reflect currentnutritional trends in management for people with diabetes.

Hyperlipidemia. Almost all of the risk factors for athero-sclerosis and coronary heart disease identified in populationstudies are overrepresented in diabetes. Of these risk factors,plasma lipids and lipoproteins are the targets for altered di-etary habits. Such alteration must be qualified with an un-derstanding of the relationship between diabetes mellitus andlipoprotein metabolism and evidence of a favorable outcomeof a fat-modified diet on this relationship.

The following conclusions can be drawn from the litera-ture. I) In untreated diabetes mellitus, the serum concen-tration of LDL cholesterol is within normal limits. Hyper-lipidemia, if present, involves an increase in serum triglyceride,very-low-density lipoprotein (VLDL) triglyceride, and VLDLcholesterol concentrations. High-density lipoprotein (HDL)cholesterol levels may also be decreased, particularly inNIDDM. 2) Diabetes mellitus and familial hyperlipoprotein-emias are not genetically coinherited. Their frequent co-existence could result from their independent associationwith other metabolic disorders such as obesity. 3) The mech-anism of the lipoprotein disorder in diabetes affects the me-tabolism of plasma VLDL, LDL, and HDL. The disordergreatly relates to the metabolic milieu of the diabetic syn-drome, although the mechanism(s) of increased apolipopro-tein B production and decreased HDL cholesterol concen-tration observed in some diabetic individuals remains unknown.4) Treatment of hyperglycemia is associated with improve-ment in plasma VLDL and LDL concentrations and can beaccompanied by improvement in plasma HDL levels, partic-ularly when associated conditions such as obesity are simul-taneously treated. 5) Epidemiological surveys, dietary inter-vention trials, and studies in experimental animals providestrong evidence that fat and cholesterol restriction couldexert favorable influences on plasma lipid and lipoproteinlevels as well as on cardiovascular risk.

Based on these conclusions, the following recommenda-tions are made. I) Because of the high risk of cardiovasculardisease (CVD) among subjects with diabetes, and the knownassociation between abnormalities in plasma lipids and li-poprotein concentrations and increased CVD risk, and be-cause of the established favorable effects of a fat-modifieddiet on plasma lipids and lipoprotein concentrations, as aminimal requirement, subjects with diabetes should be pre-scribed a fat-modified diet in which total fat is restricted to<30% of the total calories: saturated fat <10%, polyunsat-urated fat <10% (preferably 6-8%), and the rest as mon-ounsaturated fat. The cholesterol content should not be >300mg/day. These recommendations are comparable with thoseof the American Heart Association (AHA) Phase I, recom-

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mended for the American public at large. Liberalization ofthe carbohydrate intake, of the unrefined variety, may alsobe beneficial in the management of hyperlipidemia. 2) Be-cause normolipemia may not be achieved with optimal an-tidiabetic therapy in some subjects, presumably due to co-existence of diabetes and a disorder of lipoprotein metabolism,a stricter fat-modified diet (comparable with that of the AHAPhase II: fat 25% of calories; cholesterol 200-250 mg/day;or Phase III: fat 20% of calories, cholesterol 100-150 mg/day) should be prescribed for individuals who continue toexhibit persistently elevated LDL cholesterol. Note that un-der these circumstances, protein intake will have to be lib-eralized. These diet plans should be carefully constructed bya nutritionist. Additional hypolipidemic agents may also benecessary. Individuals who continue to exhibit an increasein VLDL triglyceride and cholesterol concentrations are notlikely to benefit from the stricter fat-modified diets of AHAPhases II and III. Because these are probably due to lipopro-teinemic disorders, e.g., familial combined hyperlipidemia,their management, in addition to the AHA Phase I diet,includes hypolipidemic agents appropriate for the treatmentof these disorders. 3) In the unusual circumstance of massivehypertriglyceridemia (plasma triglycerides 1000-2000 mg/dl)in which the danger of acute pancreatitis is high, the dietaryfat intake should be restricted initially to 10-20% of totalcalories together with appropriate antidiabetic therapy, man-agement of accompanying causes of secondary hyperlipid-emia, and possibly a fibric acid derivative.

These recommendations should be further modified to ac-commodate the nutritional management of accompanyingdisorders, e.g., obesity, hypertension, and renal disease. Inaddition, appropriate medical management of other risk fac-tors for coronary heart disease, e.g., cigarette smoking andhypertension, should be emphasized.

Protein intake. The average American eats more proteinthan is necessary to maintain normal health. Traditionally,diabetic dietary recommendations have emphasized protein.However, there is growing evidence that protein intake shouldbe reduced in individuals who are identified at risk for orwho have clinical evidence of nephropathy. The Recom-mended Dietary Allowance (RDA) for protein is 0.8 g/kgbody wt for adults. Many of the foods that are being en-couraged for their fiber content, e.g., legumes, are also highin protein, and care must be exercised in their prescription.An acute catabolic state will increase the need for proteinthat must be met. During gestation, lactation, and periodsof rapid growth, there is a modest increased need for protein.Elderly subjects may have greater protein requirements thanthe RDA.

Exercise and energy requirements. The energy content ofthe diet should be adjusted to meet the energy requirementsof the individual patient. Because most people with IDDMare thin when first diagnosed, a diet adequate for normalgrowth and development in children and adolescents andadults should be a major goal. Attention should be given tomeet the energy needs of the individual's habitual level ofphysical activity and to compensate for the increased nutri-

tional requirements of special situations, e.g., pregnancy,lactation, or other hypermetabolic conditions.

When obesity is present, as is common with NIDDM, theenergy content of the diet should be 2=500 kcal/day belowenergy requirements to promote weight loss and attainmentof a reasonable body weight.

Sodium. Individuals with diabetes, as well as the generalpublic, are cautioned to avoid using too much sodium. So-dium is essential to the human body, but most Americansconsume much more than necessary, especially from proc-essed foods. Table salt, which is 40% sodium, is added tomany foods in processing. A daily intake of 1000 mg ofsodium per 1000 kcal not to exceed 3000 mg is recommendedby the AHA. The principal concern with high sodium con-sumption is directed toward people with hypertension andthose susceptible to the development of hypertension. Noteveryone is sodium sensitive, but because people with dia-betes are frequently hypertensive, it seems prudent, especiallyin relationship to complications, to make modest restrictionson sodium intake. In patients with diabetes that is severelyout of control or who have problems with fluid balance orpostural hypotension, salt may be beneficial, and medicalrecommendations for its use should be made.Alternative sweeteners.

1. The use of alternative sweeteners of both the noncaloric(e.g., aspartame and saccharin) and the caloric varieties (e.g.,fructose and sorbitol) is acceptable in the management ofdiabetes. However, the use of caloric sweeteners (e.g., fruc-tose and sorbitol) in the belief that their energy contributionis not significant may undermine efforts to lose weight andcould lead to weight gain. They cannot be substituted intothe meal plan for noncaloric sweeteners, because their caloriccontribution may be substantial and must be accounted forin the meal plan. Individuals in whom diabetes is reasonablywell controlled may use fructose or sorbitol without adverseshort-term effects on blood glucose. The metabolic effects ofchronic ingestion of diets containing fructose and/or sorbitolneed further study to establish whether their use as part ofdiabetes management is beneficial. There is no evidence,however, that ingested sorbitol can gain access to the internalcellular milieu and contribute to the complications of dia-betes.

2. If sweeteners are used, the use of various sweeteners,each with its particular advantages, is recommended to dis-tribute any potential risks.

3. Excessive intake of any sweetener requires nutritionalcounseling. Individual ingestion of sweetener should be lim-ited to the established safe levels when such figures are avail-able. The limitation of any sweetener, however, should beindividualized and take into consideration other sweeteneruse and overall diet and nutritional adequacy.

4. Better labeling is needed to inform consumers about thesweeteners contained in food. Food labels should list thespecific individual sweeteners and their amounts (in mg org) per serving.

5. Continued research is needed to identify the risks aswell as metabolic effects of long-term use of individual sweet-

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eners and combinations of sweeteners in humans, particularlyin individuals with diabetes. Because their intake as a groupmay be greater than that of the general population, specificstudies on children, adolescents, and adults are needed. Moreinformation is needed about the diabetic palate and the pref-erence for sweetness in children and adults to determineactual needs for alternative sweeteners.

Alcohol. The same precautions regarding the use of alcoholthat apply to the general public apply to people with diabetes.There are, however, additional considerations for glycemiccontrol, prevention of hypoglycemia, hyperlipidemia, andweight control. If used, alcohol should be taken in moder-ation, i.e., not more than 2 equivalents of an alcoholicbeverage once or twice a week. One equivalent or 1 oz ofliquor is equal to the amount of alcohol in a 1.5-oz shot ofdistilled beverage, a 4-oz glass of wine, or 12 oz of beer. Lightbeer and dry wine may be better choices because of the lessercarbohydrate content than regular beer or wine. Alcoholicbeverages should be consumed with food. For IDDM indi-viduals, 2 oz of an alcoholic beverage may be taken in ad-dition to the regular meal plan. No food should be omitted,because alcohol-induced hypoglycemia may occur and be-cause alcohol does not require insulin for its metabolism. ForNIDDM individuals, alcohol is best substituted for fat ex-changes because it is high in kilocalories and because it ismetabolized like fat (1 oz = 2 fat exchanges). These rec-ommendations should not be used to encourage alcohol usein people with diabetes who risk alcohol abuse.

SPECIAL CONSIDERATIONS FOR IDDM

The meal plan is important for avoiding hyperglycemia, pre-venting hypoglycemia, and maintaining metabolic balance.Whether it plays a specific role in preventing or delaying theneuropathic, microvascular, or macrovascular complicationsassociated with IDDM is still under review. Consistency offood intake is very important in the treatment of IDDM.The following must be considered when preparing a mealplan for infants, children, adolescents, and adults with IDDM:I) timing of meals and snacks; 2) composition of food; 3)energy content; 4) level of physical activity; 5) age, sex, andpubertal status of patient; 6) growth assessment; and 7) preg-nancy and lactation needs.

Timing and consistency of food. The time at which mealsare taken, how much time elapses between insulin injectionand food intake, and the number of meals and snacks eateneach day should be dictated by individual needs. The needscan be determined by capillary blood glucose monitoring andattention to life-style, physical activity, insulin effect, andadministration. Day-to-day consistency is crucial to coun-terbalance other aspects of IDDM treatment. Timing of snacksmay change with the use of pure pork or human insulin andtheir different peak effects and duration of action.

Meal plan composition. For most patients with IDDM, nu-tritional recommendations are those in the general outline.

Energy content. Height and weight data must be plotted

routinely until growth is completed and to help prevent obe-sity. Nutritional prescriptions should be adjusted to meet theneeds for normal growth.

Special situations. Although all meal plans should be in-dividualized, certain circumstances require attention in pa-tients with IDDM: 1) the youngster who is a picky eater (i.e.,no vegetables); 2) people with eating disorders (i.e., obesity,bulimia, anorexia nervosa); 3) people with gastrointestinaldisease (i.e., Crohn's colitis, celiac disease, giardiasis, im-munoglobulin A deficiency); 4) people with low iron stores(i.e., positive gastroparietal antibodies with achlorhydria),which may require vitamin or mineral supplementation; and5) people, especially pregnant women and very young chil-dren with IDDM, who use nutritive and nonnutritive sweet-eners.

In IDDM people, total daily energy intake should be dis-tributed consistently throughout the day with at least threeregular meals, a bedtime snack, and one or more between-meal snacks. If the patient is taking two or more injectionsof short-acting insulin daily or is using short-acting insulinas a supplement to the longer-acting insulins, greater flexi-bility in meals may be allowed by adjustment of insulin dos-age. This decision, however, should be made after discussionwith the physician and nutritionist and should be based onthe results of glucose monitoring.

Dietary adjustments for exercise. Because physical activitymay vary considerably from day to day, adjustments in energyintake and insulin dosage may be required to avoid hypogly-cemia in insulin-treated patients. Metabolic fuel utilizationduring exercise depends on many factors, e.g., the intensityand duration of exercise, the level of physical training, theantecedent diet, and the metabolic state of the individual.In IDDM individuals, vigorous exercise should be undertakenonly if blood glucose is in the range of 100-200 mg/dl andthere is no ketosis. If the preexercise blood glucose concen-tration is too low, exercise may result in hypoglycemia; if itis too high and there is insulin deficiency, exercise may causea further increase in blood glucose and ketosis.

Several strategies may be used to avoid hypoglycemia dur-ing or after vigorous, prolonged, or nonhabitual exercise inIDDM patients. Supplemental carbohydrate-containing snacksmay be taken before and during exercise to maintain bloodglucose within the normal range, and increased energy in-take, primarily as carbohydrate, may be needed for up to 24h after exercise to provide for repletion of muscle as well asliver glycogen stores and to prevent postexercise hypogly-cemia. The amount and frequency of supplemental feedingsmay be estimated from predicted rates of glucose oxidationduring exercise or empirically from self-monitoring of bloodglucose.

In addition, adjustments in insulin dosage and timing maybe needed to prevent exercise-induced hypoglycemia. Thisshould always be done after consultation with the physicianand the health-care team. Individuals taking a single dose ofintermediate-acting insulin may, after consultation with thephysician, decrease the usual dose by 30-35% before vigorousor prolonged exercise and may take a second dose later in

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the day if necessary. Those on combined intermediate- andshort-acting insulin schedules may need to reduce or omitthe short-acting insulin and decrease the intermediate-actinginsulin before exercise. If a multiple-dose regimen with pri-marily short-acting insulin or an insulin-infusion device isused, the dosage before exercise may need to be reduced by^50% and supplemental insulin taken after exercise, de-pending on the results of glucose self-monitoring. In general,it is best to avoid exercise within 1 h after an insulin injectionto prevent rapid absorption and hyperinsulinemia during ex-ercise. When this is not possible, the preexercise dose ofinsulin should be injected in a nonexercising area to minimizethe exercise-enhanced absorption. Because individual pat-terns of exercise are extremely variable, the most effectivecombination of supplemental feeding and adjustment of in-sulin dosage may depend on frequent glucose self-monitoringand previous experience.

Intensified insulin therapy. This poses two potential prob-lems. If successful, hypoglycemic events may occur morefrequently. Such intensified therapies (multidose insulin and/or continuous subcutaneous insulin infusion are also asso-ciated with weight gain reflected in more positive energybalance.

SPECIAL CONSIDERATIONS FOR N1DDM

There are special needs for obese patients. Dietary interven-tions directed toward weight reduction and improvement inblood glucose and lipids of the obese person with NIDDMhave the greatest potential for a significant positive effect onmorbidity and mortality. Individuals who are both obese andhave diabetes are at far greater risk than those who are onlyobese. The metabolic improvements achieved with weightreduction of obese diabetic patients are indisputable and in-clude reduction in hyperglycemia, hyperlipidemia, hyperten-sion, and proteinuria. Weight reduction also leads to moregeneral benefits, including improved pulmonary function,reduced risks at operation, and reduction of musculoskeletalproblems. In addition, the improvement in glucose tolerancewith reduction of caloric intake may reduce or eliminate theneed for oral hypoglycemic agents or insulin. The timing ofweight loss relative to the progression of diabetes may be ofcritical importance to the long-term prognosis and, possibly,to the delay of onset or prevention of the development ofcomplications.

Attention should be given to individuals with upper-bodyfat localization because this form of obesity, even when mild,is associated with higher glucose levels, exacerbated insulinresistance, greater abnormality of the lipoprotein profile, andincreased cardiovascular risk. Although much is still un-known about the relative merits of various weight-reductionregimens, and the optimal methods for producing sustainedweight loss have to be identified, several features should beconsidered in making a choice among the available ap-proaches.

1. The diet should be nutritionally balanced and the cal-orie level restricted. A weight-reducing diet should be nu-

tritionally complete, providing for various foods. Moderatecaloric restriction of 500-1000 kcal below usual daily foodintake levels may be optimal in producing gradual sustainedweight loss. Under professional supervision, very-low-caloriediets (500-800 kcal/day) can be effective and safe for se-verely obese NIDDM individuals, particularly where there isa need for rapid and significant weight reduction. Vitaminand mineral supplementation should be used to meet theRDA.

2. A maintenance program should be provided. After suc-cessful weight loss, there is often great difficulty in sustainingthe reduced body weight. It appears that stabilization of bodyweight at a reduced level requires the continued ingestion ofa restricted calorie level and a lifelong commitment to sus-taining the reduced weight. The prevention of recidivismwith regaining of lost weight requires greater attention if thebenefits of reducing body weight of the obese are to be re-alized.

Although normalization of body weight is a desirable goal,even modest caloric restriction per se may be beneficial dueto the positive effects on blood glucose and requirements forinsulin and oral antidiabetic agents.

3. Energy requirements for exercise in NIDDM individualsare not significantly different from those of nondiabetic peo-ple. Supplemental food before and during exercise is notneeded to prevent hypoglycemia and is not recommended,except under conditions of severe, prolonged exercise suchas endurance sports. In patients taking sulfonylureas there isa slight increased risk of hypoglycemia during exercise, andsupplemental intake may be required in some cases. This maybe determined by glucose self-monitoring. NIDDM individ-uals taking insulin should usually decrease their insulin dosagebefore exercise and may take supplemental food if needed toprevent hypoglycemia during or after exercise.

Physical exercise may be used as an adjunct to low-caloriediets for weight reduction in obese NIDDM patients. Exercisealone, without concurrent caloric restrictions, rarely resultsin significant weight loss. When the energy content of thediet is severely restricted (<1000 kcal/day), carbohydrateintake should be maintained to preserve normal muscle gly-cogen stores and the capacity for vigorous exercise and en-durance.

SPECIAL NEEDS OF MINORITY PATIENTS

Diet therapy for minority patients must be directed to themost common form of diabetes, NIDDM, and tailored to theculture of the population. Educators must utilize techniquesand written materials appropriate for the patient and thefamily. Nutrition information can be divided into sequential,manageable steps, which can then be individualized into thepatient's setting. Appropriate traditional, ethnic, and cul-tural foods can be encouraged. No simple set of exchangelists will suffice for all minority groups. Because food groupingmay be abstract, exchange lists may be inappropriate for allsituations. Simple, single-concept messages should be de-veloped that can be adapted to the foods of specific groups.

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SUMMARY

The management of diabetes requires a careful balance be-tween nutrient intake, energy expenditure, and the dose andtiming of oral hypoglycemic agents and/or insulin. Mealplanning should commence with an initial teaching of sur-vival skills and a goal-oriented progression through phases ofincreasing information acquisition, incorporation of infor-mation into new knowledge and skills, a program of contin-uing education, and reinforcement with an ultimate changein the behavior pattern. These tasks are best accomplishedby a multidisciplinary team approach that uses various skillsin nutrition planning and health care. The use of preprinted,handout diet plans is strongly discouraged.

The need for essential basic nutrients is the same for allpeople of equivalent age, sex, and size, diabetic or not. Thenutrient needs of diabetic people can usually be met withoutthe use of special dietetic or diabetic foods. Calories shouldbe prescribed according to energy needs to achieve and main-tain a desirable body weight. The amount of carbohydrateshould be liberalized. Whenever possible and acceptable tothe patient, natural foods containing unrefined carbohydrateshould be substituted for the highly refined carbohydratesthat are low in fiber. The use of supplemental fiber is ac-ceptable within the limits defined above. In some individuals,modest amounts of refined carbohydrates are acceptable, de-pending on weight control and impact on blood glucose andserum lipid concentrations.

The high risk of macrovascular disease in patients withdiabetes and associated hyperlipidemia dictates a need torestrict total fat intake and cholesterol and replace saturatedfats with unsaturated fats to slow the progression of athero-sclerotic disease. The use of supplemental eicosapentanoicacids may be acceptable, but more research into the benefitsis needed.

Foods with low glycemic indices may be tried for theiroverall effect in the diets of given individuals. Recommen-dations made for meal planning should be based on an up-dated version of the food exchanges. At a later stage theselists may be formally supplemented with information on lowglycemic index selections. No food exchange list is applicableto all groups of people. However, in minority groups, spe-

cialized and simplified initial single-concept approaches arerecommended. Food selection in these groups must take intoconsideration socioeconomic, cultural, and ethnic factors.

Americans eat far more protein and salt than is requiredfor optimum nutrition. Protein intake should be restrictedto the RDA except in groups at risk of negative nitrogenbalance. In the future, tests may be devised to predict whichindividuals are at risk of nephropathy and would benefit fromsevere protein restriction. Limited salt intake is also advised.

Particular nutritive and nonnutritive sweeteners are notencouraged but are acceptable. Use of various nonnutritivesweeteners is encouraged to offset the possible disadvantagesthat may result from excessive consumption of a single agent.

People with diabetes are under the same restrictions inregard to the use of alcohol as the general population, withparticular attention to alcoholic hypoglycemia.

These recommendations are based on current knowledge.Nutrition science is a rapidly growing and dynamic field inwhich what is sound practice today may not be so tomorrow.These recommendations are, however, similar to those ad-vocated by diabetes associations throughout the world andby the American Heart and Cancer Associations and theAmercian Academy of Pediatrics. Nonetheless, there aremany unanswered questions, and answers will only be possiblewith support for diligent research into these areas. By con-tinued endeavors and timely revisions of these guidelines,Americans should benefit greatly from new knowledge in thearea of nutrition.

The recommendations and principles were approved bythe Board of Directors, 18 October 1986, and developed bya task force of the American Diabetes Association:Aaron I. Vinik, MD, ChairmanPhyllis A. Crapo, RD, Vice-ChairmanStuart J. Brink, MDMarion J. Franz, RD, MSDorothy M. Gohdes, MDBarbara C. Hansen, PhDEdward S. Horton, MDDavid Jenkins, MDAhmed Kissebah, MDAndrea Lasichak, RDJudith Wylie-Rosett, EDD, RD

132 DIABETES CARE, VOL. 10 NO. 1, JANUARY-FEBRUARY 1987