"The goal of these recommendations is to make people with diabetes and health care providers aware of beneficial nutrition interventions," write John P. Bantle, and colleagues from the ADA. "This requires the use of the best available scientific evidence while taking into account treatment goals, strategies to attain such goals, and changes individuals with diabetes are willing and able to make. Achieving nutrition-related goals requires a coordinated team effort that includes the person with diabetes and involves him or her in the decision-making process."

Because overweight and obesity are closely associated with development of diabetes, the position statement highlights this area of MNT. The US Department of Health and Human Services (HHS) recommends primary prevention interventions to delay or prevent the development of diabetes, using public health measures to decrease the prevalence of obesity and implementing MNT in persons with prediabetes. Secondary and tertiary prevention measures recommended by HHS include MNT for patients with diabetes to prevent (secondary) or control (tertiary) diabetes complications.

In addition to listing major nutritional recommendations and interventions for diabetes, the updated position statement stresses the importance of monitoring metabolic parameters, including glucose and glycated hemoglobin levels, lipids, blood pressure, body weight, and renal function, during therapy. Such monitoring will help evaluate the need for changes in MNT and thereby optimize outcomes. The authors note that many aspects of MNT require additional research.

Some of the specific recommendations include the following:

Individuals with prediabetes or diabetes should receive individualized MNT, preferably administered by a registered dietitian knowledgeable about the components of diabetes MNT (B).
Nutrition counseling should be tailored to the personal needs of the individual with prediabetes or diabetes and his or her willingness and ability to make changes (E).
Modest weight loss in overweight and obese insulin-resistant individuals has been shown to improve insulin resistance and is therefore recommended for all such individuals who have or are at risk for diabetes (A).
In the short-term (up to 1 year), either low-carbohydrate or low-fat, energy-restricted diets may be effective for weight loss (A).
Patients receiving low-carbohydrate diets should undergo monitoring of lipid profiles, renal function, and protein intake (in patients with nephropathy), and have adjustment of hypoglycemic therapy as needed (E).
Physical activity and behavior modification aid in weight loss and are most helpful in maintaining weight loss (B).
When combined with lifestyle modification, weight loss medications may help achieve a 5% to 10% weight loss and may be considered for overweight and obese individuals with type 2 diabetes (B).
For some patients with type 2 diabetes and a body mass index of 35 kg/m2 or more, bariatric surgery can markedly improve glycemia (B).
Primary prevention for individuals at high risk of developing type 2 diabetes should include structured programs targeting lifestyle changes, with dietary strategies of decreasing energy and dietary fat intakes. Goals should include moderate weight loss (7% body weight), regular physical activity (150 minutes/week) (A), dietary fiber intake of 14 g/1000 kcal, and whole grains comprising half of total grain intake (B).
Intake of low-glycemic index foods that are rich in fiber and other vital nutrients should be encouraged (E), both for the general population and for those with diabetes.
Data do not support recommending alcohol consumption to individuals at risk for diabetes (B).
No nutritional recommendations exist to prevent type 1 diabetes (E).
Secondary prevention, or controlling diabetes, should include a healthy dietary pattern emphasizing carbohydrate from fruits, vegetables, whole grains, legumes, and low-fat milk (B).
A key strategy for achieving glycemic control is to monitor carbohydrate by counting, exchanges, or experienced-based estimation (A). Use of glycemic index and load may be modestly beneficial vs considering only total carbohydrate (B).
Sucrose-containing foods should be limited but can be substituted for other carbohydrates or covered with insulin or other glucose-lowering medications (A). Glucose alcohols and nonnutritive sweeteners are safe within daily US Food and Drug Administration intake levels (A).
Saturated fat should be limited to less than 7% of total energy (A), and trans fat should be minimized (E). In individuals with diabetes, dietary cholesterol should not exceed 200 mg/day (E).
At least 2 servings of fish per week (except for commercially fried fish) are recommended for n-3 polyunsaturated fatty acids (B).
Protein should not be used to treat acute or prevent nighttime hypoglycemia (A). High-protein diets are not recommended for weight loss (E).
If adults with diabetes choose to use alcohol, intake should be restricted to 1 drink per day or less for women and 2 drinks per day or less for men (E) and consumed with food (E).
Other topics covered in this statement regarding secondary prevention include micronutrients in diabetes management; and nutritional interventions for type 1 and type 2 diabetes, pregnancy and lactation with diabetes, and older adults with diabetes.

Application of MNT to tertiary prevention, or treating and controlling diabetes complications, may be useful for microvascular complications, treatment and management of cardiovascular risk, management of hypoglycemia, management of acute illness, management of patients with diabetes in acute healthcare facilities, and management of patients with diabetes in long-term care facilities.

"MNT is important in preventing diabetes, managing existing diabetes, and preventing, or at least slowing, the rate of development of diabetes complications," the authors conclude. "It is recommended that a registered dietitian, knowledgeable and skilled in MNT, be the team member who plays the leading role in providing nutrition care. However, it is important that all team members, including physicians and nurses, be knowledgeable about MNT and support its implementation."

Diabetes Care. 2008;31(Suppl 1):S61-S78.

Clinical Context
Appropriate nutrition is one of the cornerstones of management for both type 1 and type 2 diabetes, and a focused dietary program can have significant effects on glycemic control. Previous research has found that MNT can reduce glycated hemoglobin levels by approximately 1% among patients with type 1 diabetes and by 1% to 2% among patients with type 2 diabetes.

The ADA last published recommendations regarding MNT in 2002, which were then slightly modified in 2004. The current recommendations update these previous guidelines with an emphasis on recent research findings.

Study Highlights
Dietary advice is best provided by a registered dietician who is familiar with components of diabetes MNT.
Weight loss medications may be considered for overweight or obese patients with type 2 diabetes, as these medications may promote a weight loss of 5% to 10% of body weight when combined with lifestyle interventions.
Bariatric surgery may be considered for patients with diabetes whose body mass index exceeds 35 kg/m2. Some research has demonstrated that this surgery can lead to resolution of type 2 diabetes in more than three fourths of patients treated.
Patients at high risk of developing type 2 diabetes should be recommended to begin a lifestyle program that includes physical activity for a minimum of 150 minutes per week and consumption of 14 g of dietary fiber for every 1000 kcal of diet. These patients with obesity should set a target of losing approximately 7% of body weight.
There is not conclusive evidence that low-glycemic diets reduce the risk for diabetes, although these diets may be helpful because of their high fiber content. These diets should not be routinely recommended to patients with prediabetes.
Moderate alcohol use may reduce the risk for diabetes, although clinicians should not recommend alcohol use for this purpose.
Among patients consuming a high-glycemic diet, converting to a low-glycemic index diet can provide some modest benefit in postprandial hyperglycemia.
Glucose alcohols and nonnutritive sweeteners may be used in moderation by patients with diabetes.
Dietary fat should not comprise more than 7% of total energy per day, and dietary cholesterol intake should be less than 200 mg per day.
There is insufficient evidence to recommend that patients with diabetes should consume a higher amount of protein vs other adults without diabetes. Foods rich in protein should not be used to treat hypoglycemia.
The authors recommend against high-protein diets for weight loss among patients with diabetes. The benefits of these diets for body mass may be short-lived, and there are limited data on long-term renal complications associated with high-protein diets.
Routine use of dietary supplements or vitamins is not recommended for patients with diabetes. However, older adults with reduced energy intake may benefit from a daily multivitamin.
Protein intake should not exceed 1 g per kg of body weight per day among patients with early chronic kidney disease, and this upper limit of intake should decrease to 0.8 g/kg of body weight per day in the later stage of kidney disease.
Hypoglycemia should be treated with 15 to 20 g of glucose, or a similar carbohydrate equivalent. The response to this treatment should occur between 10 and 20 minutes.
Pearls for Practice
Previous research has suggested that MNT can reduce glycated hemoglobin levels by approximately 1% for patients with type 1 diabetes and 1% to 2% for patients with type 2 diabetes.
The current guidelines do not recommend low-glycemic index or high-protein diets for the routine treatment of patients with diabetes. Moreover, most patients with diabetes should not routinely receive supplements or vitamins.

(The article medscape.com)

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