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They are often disaggregated by district or locality, but are not always representative, since they often refer only to users of the services under consideration. This is particularly true in those using insulin or insulin secretagogue therapies. New collection procedures often have to be introduced for use by local units, while being careful not to overload them or divert them from their own work. Partners with the UK's smartest companies. In the Look AHEAD study, participants with early-stage diabetes shortest duration, not treated with insulin, good baseline glycemic control received the most health benefits with a small percentage of individuals achieving partial or complete diabetes remission Screening Early recognition of nutrition-related issues is necessary for appropriate nutrition management of cancer patients. In addition, two RCTs compared the efficacy of plant sterol consumption 1.
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Am Surg ;44 4: Decreasing the incidence of surgical wound infections: Arch Surg ; 4: Comparison of case-finding methodologies for endometritis after cesarean section. Am J Infect Control ;23 1: Validation of surgical wound surveillance. Infect Control Hosp Epidemiol ;14 4: The impact of depth of infection and postdischarge surveillance on rate of surgical-site infections in a network of community hospitals.
Infect Control Hosp Epidemiol ;33 3: Highly sensitive and efficient computer-assisted system for routine surveillance for surgical site infection. Infect Control Hosp Epidemiol ;27 8: Enhanced identification of postoperative infections among outpatients. Emerg Infect Dis ;10 Enhanced identification of postoperative infections among inpatients.
Use of Medicare claims to identify US hospitals with a high rate of surgical site infection after hip arthroplasty. Infect Control Hosp Epidemiol ;34 1: Use of Medicare claims to rank hospitals by surgical site infection risk following coronary artery bypass graft surgery. Infect Control Hosp Epidemiol ;32 8: Use of administrative data in efficient auditing of hospital-acquired surgical site infections, New York State — Infect Control Hosp Epidemiol ;33 6: Infection control—a problem for patient safety.
N Engl J Med ; 7: Ambulatory surgery in the United States, Natl Health Stat Report ; National action plan to prevent health care—associated infections: Department of Health and Human Services website. Accessed January 4, Consensus paper on the surveillance of surgical wound infections. Infect Control Hosp Epidemiol ;13 Impact of postdischarge surveillance on surgical site infection rates for several surgical procedures: Post-discharge surgical wound infection surveillance in a provincial hospital: ANZ J Surg ;71 Surveillance of surgical site infections in alternative settings: Am J Infect Control ;25 2: Improved detection of orthopaedic surgical site infections occurring in outpatients.
Clin Orthop Relat Res Infection control in ambulatory care. Infect Dis Clin North Am ;11 2: Methods for identifying surgical wound infection after discharge from hospital: BMC Infect Dis ;6: Am J Infect Control ;33 1: J Hosp Infect ;52 3: Manian FA, Meyer L. Comparison of patient telephone survey with traditional surveillance and monthly physician questionnaires in monitoring surgical wound infections.
Surveillance for surgical site infection after hospital discharge: Infect Control Hosp Epidemiol ;27 Surgical site infections occurring after hospital discharge. J Infect Dis ; 4: Accessed January 5, Accessed January 6, Prevention and Treatment of Surgical Site Infection. Accessed February 12, Antimicrobial prophylaxis for surgery: Clin Infect Dis ;38 The surgical infection prevention and surgical care improvement projects: Clin Infect Dis ;43 3: Hospitals collaborate to decrease surgical site infections.
The Society of Thoracic Surgeons practice guideline series: Ann Thorac Surg ;87 2: A resource from the Institute of Healthcare Improvement.
Accessed January 31, The Joint Commission, Accessed March 1, Fed Regist ;77 Medicare program; hospital inpatient value-based purchasing program. Fed Regist ;76 Quality improvement of surgical prophylaxis in Dutch hospitals: J Antimicrob Chemother ;56 6: Stamping out surgical site infections. A system and process redesign to improve perioperative antibiotic administration.
Anesth Analg ; 6: Implementing antibiotic practice guidelines through computer-assisted decision support: Ann Intern Med ; Reducing surgical site infections through a multidisciplinary computerized process for preoperative prophylactic antibiotic administration. Am J Surg ; 5: Anesth Analg ; 5: Computerized physician order entry: J Am Med Inform Assoc ;11 2: Antimicrobial prophylaxis for surgery.
Treat Guidel Med Lett ;7 Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm ;70 3: Timing of antimicrobial prophylaxis and the risk of surgical site infections: Ann Surg ; 1: Antibiotic prophylaxis and the risk of surgical site infections following total hip arthroplasty: Clin Infect Dis ;44 7: Timing of antibiotic prophylaxis for primary total knee arthroplasty performed during ischemia.
Clin Infect Dis ;46 7: Timing of antibiotic prophylaxis in tourniquet surgery. J Foot Ankle Surg ;50 4: Prolonged antibiotic prophylaxis after cardiovascular surgery and its effect on surgical site infections and antimicrobial resistance. Single- versus multiple-dose antimicrobial prophylaxis for major surgery: Aust N Z J Surg ;68 6: Postoperative antibiotics correlate with worse outcomes after appendectomy for nonperforated appendicitis.
J Am Coll Surg ; 6: Preoperative oral antibiotics reduce surgical site infection following elective colorectal resections. Dis Colon Rectum ;55 A statewide assessment of surgical site infection following colectomy: Ann Surg ; 3: Colon preparation and surgical site infection. Am J Surg ; 2: Antibiotic choice is independently associated with risk of surgical site infection after colectomy: Oral versus systemic antibiotic prophylaxis in elective colon surgery: Can J Surg ;45 3: Antimicrobial prophylaxis for colorectal surgery.
Cochrane Database Syst Rev ; 1: Choice of intravenous antibiotic prophylaxis for colorectal surgery does matter. J Am Coll Surg ; 5: Oral antibiotic bowel preparation reduces length of stay and readmissions after colorectal surgery. J Am Coll Surg ; 4: Mechanical bowel preparation for elective colorectal surgery.
Cochrane Database Syst Rev ; 9: Preoperative hair removal to reduce surgical site infection. Cochrane Database Syst Rev ; 3: Long-term glycemic control and postoperative infectious complications. Perioperative glycemic control and the risk of infectious complications in a cohort of adults with diabetes. Diabetes Care ;22 9: Risk factors for surgical site infection following orthopaedic spinal operations.
J Bone Joint Surg Am ;90 1: Importance of perioperative glycemic control in general surgery: Randomized study of basal-bolus insulin therapy in the inpatient management of patients with type 2 diabetes undergoing general surgery RABBIT 2 surgery. Diabetes Care ;34 2: Guidelines for the use of an insulin infusion for the management of hyperglycemia in critically ill patients. Crit Care Med ;40 Management of hyperglycemia in hospitalized patients in non—critical care setting: J Clin Endocrinol Metab ;97 1: Intensive intraoperative insulin therapy versus conventional glucose management during cardiac surgery: Ann Intern Med ; 4: Complications and treatment of mild hypothermia.
Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. N Engl J Med ; Effects of preoperative warming on the incidence of wound infection after clean surgery: Randomized clinical trial of perioperative systemic warming in major elective abdominal surgery. Br J Surg ;94 4: Supplemental perioperative oxygen and the risk of surgical wound infection: Supplemental perioperative oxygen to reduce the incidence of surgical-wound infection.
N Engl J Med ; 3: Perioperative hyperoxygenation and wound site infection following surgery for acute appendicitis: Effect of high perioperative oxygen fraction on surgical site infection and pulmonary complications after abdominal surgery: Surgical site infection and the routine use of perioperative hyperoxia in a general surgical population: J Gastrointest Surg ;16 2: Prevention of anastomotic leakage after total gastrectomy with perioperative supplemental oxygen administration: Ann Surg Oncol ;20 5: Increased long-term mortality after a high perioperative inspiratory oxygen fraction during abdominal surgery: Anesth Analg ; 4: Perioperative supplemental oxygen therapy and surgical site infection: Maiwald M, Chan ES.
The forgotten role of alcohol: PloS ONE ;7 9: Chlorhexidine-alcohol versus povidone-iodine for surgical-site antisepsis. N Engl J Med ; 1: Effects of preoperative skin preparation on postoperative wound infection rates: Infect Control Hosp Epidemiol ;30 Aly R, Maibach HI. Comparative antibacterial efficacy of a 2-minute surgical scrub with chlorhexidine gluconate, povidone-iodine, and chloroxylenol sponge-brushes. Am J Infect Control ;16 4: Guideline for use of topical antimicrobial agents.
Am J Infect Control ;16 6: Wound protectors reduce surgical site infection: A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med ; 5: Effect of a item surgical safety checklist during urgent operations in a global patient population. Ann Surg ; 5: The efficacy of infection surveillance and control programs in preventing nosocomial infections in US hospitals.
Am J Epidemiol ; 2: Infect Dis Clin North Am ;6 3: Use of Medicare diagnosis and procedure codes to improve detection of surgical site infections following hip arthroplasty, knee arthroplasty, and vascular surgery. Infect Control Hosp Epidemiol ;33 1: Improved surveillance for surgical site infections after orthopedic implantation procedures: Clin Infect Dis ;48 9: Evaluation study of different strategies for detecting surgical site infections using the hospital information system at Lyon University Hospital, France.
Enhanced surgical site infection surveillance following hysterectomy, vascular, and colorectal surgery. Infect Control Hosp Epidemiol ;33 8: Cochrane Database Syst Rev ; 2: Improving awareness of best practices to reduce surgical site infection: Am J Med Qual ;27 4: Association of periOperative Registered Nurses. Accessed March 23, Surgical wound infection rates by wound class, operative procedure, and patient risk index.
Am J Med ;91 3B: Multiple reservoirs contribute to intraoperative bacterial transmission. Traffic flow in the operating room: Am J Infect Control ;40 8: Reduction of surgical site infections after implementation of a bundle of care. Mupirocin ointment for preventing Staphylococcus aureus infections in nasal carriers. Cochrane Database Syst Rev ; 4: Use of perioperative mupirocin to prevent methicillin-resistant Staphylococcus aureus MRSA orthopaedic surgical site infections.
J Hosp Infect ;54 3: Controlling the usage of intranasal mupirocin does impact the rate of Staphylococcus aureus deep sternal wound infections in cardiac surgery patients. Am J Infect Control ;34 1: Sustained reduction in methicillin-resistant Staphylococcus aureus wound infections after cardiothoracic surgery.
Arch Intern Med ; 1: Preventing surgical-site infections in nasal carriers of Staphylococcus aureus. Universal screening for methicillin-resistant Staphylococcus aureus at hospital admission and nosocomial infection in surgical patients. Intranasal mupirocin to prevent postoperative Staphylococcus aureus infections. There is very limited research in people with diabetes and without kidney disease on the impact of the type of protein consumed.
One study did not find a significant difference in glycemic or lipid measures when comparing a chicken- or red meat—based diet For individuals with diabetic kidney disease and macroalbuminuria, changing the source of protein to be more soy-based may improve CVD risk factors but does not appear to alter proteinuria , For individuals with type 2 diabetes, protein does not appear to have a significant effect on blood glucose level , but does appear to increase insulin response , , For this reason, it is not advised to use protein to treat hypoglycemia or to prevent hypo-glycemia.
Evidence is inconclusive for an ideal amount of total fat intake for people with diabetes; therefore, goals should be individualized. C Fat quality appears to be far more important than quantity.
Currently, insufficient data exist to determine a defined level of total energy intake from fat at which risk of inadequacy or prevention of chronic disease occurs, so there is no adequate intake or recommended daily allowance for total fat These recommendations are not diabetes-specific; however, limited research exists in individuals with diabetes.
Fatty acids are categorized as being saturated or unsaturated monounsaturated or polyunsaturated. Trans fatty acids may be unsaturated, but they are structurally different and have negative health effects The type of fatty acids consumed is more important than total fat in the diet in terms of supporting metabolic goals and influencing the risk of CVD 83 , , ; thus more attention should be given to the type of fat intake when individualizing goals.
Individuals with diabetes should be encouraged to moderate their fat intakes to be consistent with their goals to lose or maintain weight. In people with type 2 diabetes, a Mediterranean-style, monounsaturated fatty acid MUFA -rich eating pattern may benefit glycemic control and CVD risk factors and can, therefore, be recommended as an effective alternative to a lower-fat, higher-carbohydrate eating pattern.
Evidence from large prospective cohort studies, clinical trials, and a systematic review of RCTs indicate that high-MUFA diets are associated with improved glycemic control and improved CVD risk or risk factors 70 , — The intake of MUFA-rich foods as a component of the Mediterranean-style eating pattern has been studied extensively over the last decade.
However, some of the studies also included caloric restriction, which may have contributed to improvements in glycemic control or blood lipids , In , the Evidence Analysis Library EAL of the Academy of Nutrition and Dietetics found strong evidence that dietary MUFAs are associated with improvements in blood lipids based on 13 studies including participants with and without diabetes.
There is limited evidence in people with diabetes on the effects of omega-6 polyunsaturated fatty acids PUFAs. Controversy exists on the best ratio of omega-6 to omega-3 fatty acids; PUFAs and MUFAs are recommended substitutes for saturated or trans fat , Evidence does not support recommending omega-3 EPA and DHA supplements for people with diabetes for the prevention or treatment of cardiovascular events.
As recommended for the general public, an increase in foods containing long-chain omega-3 fatty acids EPA and DHA from fatty fish and omega-3 linolenic acid ALA is recommended for individuals with diabetes because of their beneficial effects on lipoproteins, prevention of heart disease, and associations with positive health outcomes in observational studies. The recommendation for the general public to eat fish particularly fatty fish at least two times two servings per week is also appropriate for people with diabetes.
The ADA systematic review identified seven RCTs and one single-arm study — using omega-3 fatty acid supplements and one cohort study on whole-food omega-3 intake. In individuals with type 2 diabetes 88 , supplementation with omega-3 fatty acids did not improve glycemic control, but higher-dose supplementation decreased triglycerides. Additional blood-derived markers of CVD risk were not consistently altered in these trials.
Three longer-duration studies 4 months ; 40 months ; 6. Two studies reported no beneficial effects of supplementation , No differences on estimated year CVD risks were observed with the addition of omega-3 fatty acid supplements compared with placebo Thus, RCTs do not support recommending omega-3 supplements for primary or secondary prevention of CVD despite the strength of evidence from observational and preclinical studies.
Previous studies using supplements had shown mixed effects on fasting blood glucose and A1C levels. However, a study comparing diets with a high proportion of omega-3 fatty fish versus omega-6 lean fish and fat-containing linoleic acid fatty acids reported both diets had no detrimental effect on glucose measures, and both diets improved insulin sensitivity and lipoprotein profiles The amount of dietary saturated fat, cholesterol, and trans fat recommended for people with diabetes is the same as that recommended for the general population.
Few research studies have explored the relationship between the amount of SFA in the diet and glycemic control and CVD risk in people with diabetes. A systematic review by Wheeler et al. In addition, there is limited research regarding optimal dietary cholesterol and trans fat intake in people with diabetes. Due to the lack of research in this area, people with diabetes should follow the guidelines for the general population. Consumers can meet this guideline by replacing foods high in SFA i.
CVD is a common cause of death among individuals with diabetes. As a result, individuals with diabetes are encouraged to follow nutrition recommendations similar to the general population to manage CVD risk factors. Individuals with diabetes and dyslipi-demia may be able to modestly reduce total and LDL cholesterol by consuming 1. Plant sterol and stanol esters block the intestinal absorption of dietary and biliary cholesterol 3.
Currently, the EAL from the Academy of Nutrition and Dietetics recommends individuals with dyslipidemia incorporate 2—3 g of plant sterol and stanol esters per day as part of a cardioprotective diet through consumption of plant sterol and stanol ester-enriched foods This recommendation, though not specific to people with diabetes, is based on a review of 20 clinical trials These studies used doses of 1.
Two of these studies were in people with type 1 diabetes , , and one found an added benefit to cholesterol reduction in those who were already on statin treatment In addition, two RCTs compared the efficacy of plant sterol consumption 1. Neither study found a difference in lipid profiles between the two groups, suggesting that efficacy of this treatment is similar for those with and without diabetes who are hypercholesterolemic , A wide range of foods and beverages are now available that contain plant sterols including many spreads, dairy products, grain and bread products, and yogurt.
These products can contribute a considerable amount of calories. If used, patients should substitute them for comparable foods they eat in order to keep calories balanced and avoid weight gain 3 , There is no clear evidence of benefit from vitamin or mineral supplementation in people with diabetes who do not have underlying deficiencies.
Routine supplementation with antioxidants, such as vitamins E and C and carotene, is not advised because of lack of evidence of efficacy and concern related to long-term safety. There is insufficient evidence to support the routine use of micro-nutrients such as chromium, magnesium, and vitamin D to improve glycemic control in people with diabetes.
There currently exists insufficient evidence of benefit from vitamin or mineral supplementation in people with or without diabetes in the absence of an underlying deficiency 3 , , Because uncontrolled diabetes is often associated with micronutrient deficiencies , people with diabetes should be aware of the importance of acquiring daily vitamin and mineral requirements from natural food sources and a balanced diet 3. For select groups of individuals such as the elderly, pregnant or lactating women, vegetarians, and those on calorie-restricted diets, a multivitamin supplement may be necessary While there has been significant interest in antioxidant supplementation as a treatment for diabetes, current evidence not only demonstrates a lack of benefit with respect to glycemic control and progression of complications, but also provides evidence of potential harm of vitamin E, carotene, and other antioxidant supplements — A systematic review on the effect of chromium supplementation on glucose metabolism and lipids concluded that larger effects were more commonly observed in poor-quality studies and that evidence is limited by poor study quality and heterogeneity in methodology and results Evidence from clinical studies evaluating magnesium , and vitamin D — supplementation to improve glycemic control in people with diabetes is likewise conflicting.
A systematic review evaluating the effects of cinnamon in people with diabetes concluded there is currently insufficient evidence to support its use, and there is a lack of compelling evidence for the use of other herbal products for the improvement of glycemic control in people with diabetes It is important to consider that herbal products are not standardized and vary in the content of active ingredients and may have the potential to interact with other medications If adults with diabetes choose to drink alcohol, they should be advised to do so in moderation one drink per day or less for adult women and two drinks per day or less for adult men.
Alcohol consumption may place people with diabetes at increased risk for delayed hypoglycemia, especially if taking insulin or insulin secretagogues. Education and awareness regarding the recognition and management of delayed hypoglycemia is warranted. Moderate alcohol intake may also convey cardiovascular risk reduction and mortality benefits in people with diabetes — , with the type of alcohol consumed not influencing these beneficial effects , Accordingly, the recommendations for alcohol consumption for people with diabetes are the same as for the general population.
Adults with diabetes choosing to consume alcohol should limit their intake to one serving or less per day for women and two servings or less per day for men One alcohol-containing beverage is defined as 12 oz beer, 5 oz wine, or 1. Abstention from alcohol should be advised, however, for people with a history of alcohol abuse or dependence, women during pregnancy, and people with medical conditions such as liver disease, pancreatitis, advanced neuropathy, or severe hypertriglyceridemia 3. Despite the potential glycemic and cardiovascular benefits of moderate alcohol consumption, use may place people with diabetes at increased risk for delayed hypoglycemia.
This is particularly true in those using insulin or insulin secretagogue therapies. Consuming alcohol with food can minimize the risk of nocturnal hypoglycemia 3 , — Individuals with diabetes should receive education regarding the recognition and management of delayed hypoglycemia and the potential need for more frequent self-monitoring of blood glucose after consuming alcoholic beverages.
For individuals with both diabetes and hypertension, further reduction in sodium intake should be individualized. Limited studies have been published on sodium reduction in people with diabetes. A Cochrane review of RCTs found that decreasing sodium intake reduces blood pressure in those with diabetes Likewise, a small study in people with type 2 diabetes showed that following the DASH diet and reducing sodium intake to about 2, mg led to improvements in blood pressure and other measures on cardiovascular risk factors Incrementally lower sodium intakes i.
Additionally, an IOM report suggests there is no evidence on health outcomes to treat certain population subgroups—which includes individuals with diabetes—differently than the general U. When individualizing sodium intake recommendations, consideration must also be given to issues such as the palatability, availability, and additional cost of specialty low sodium products and the difficulty in achieving both low sodium recommendations and a nutritionally adequate diet given these limitations The food industry can play a major role in lowering sodium content of foods to help people meet sodium recommendations , A wide range of diabetes meal planning approaches or eating patterns have been shown to be clinically effective, with many including a reduced energy intake component.
There is not one ideal percentage of calories from carbohydrates, protein, or fat that is optimal for all people with diabetes. If the individual would like to try a different eating pattern, this should also be supported by the health care team. Various behavior change theories and strategies can be used to tailor nutrition interventions to help the client achieve specific health and quality-of-life outcomes Multiple meal planning approaches and eating patterns can be effective for achieving metabolic goals.
This may need to be adjusted over time based on changes in life circumstances, preferences, and disease course. A summary of key topics for nutrition education can be found in Table 4. The evidence presented in this position statement concurs with the review previously published by Wheeler et al. Evaluating nutrition evidence is complex given that multiple dietary factors influence glycemic control and CVD risk factors, and the influence of a combination of factors can be substantial.
Based on a review of the evidence, it is clear that gaps in the literature continue to exist and further research on nutrition and eating patterns is needed in individuals with type 1 and type 2 diabetes.
The basis for the beneficial effects of the Mediterranean-style eating pattern and approaches to translation of the Mediterranean-style eating pattern into diverse populations.
The development of standardized definitions for high— and low—glycemic index diets and implementation of these definitions in long-term studies to further evaluate their impact on glycemic control. The development of standardized definitions for low- to moderate-carbohydrate diets and determining long-term sustainability. Whether NNSs, when used to replace caloric sweeteners, are useful in reducing caloric and carbohydrate intake. The impact of key nutrients on cardiovascular risk, such as saturated fat, cholesterol, and sodium in individuals with both type 1 and type 2 diabetes.
Importantly, research needs to move away from just evaluating the impact of individual nutrients on glycemic control and cardiovascular risk. More research on eating patterns, unrestricted and restricted energy diets, and diverse populations is needed to evaluate their long-term health benefits in individuals with diabetes.
Individuals eat nutrients from foods and within the context of mixed meals, and nutrient intakes are intercorrelated, so overall eating patterns must be studied to fully understand how these eating patterns impact glycemic control 88 , Eating patterns are selected by individuals based on more than the healthfulness of food and food availability; tradition, cultural food systems, health beliefs, and economics are also important Studies on gene-diet interactions will also be important, as well as studies on potential epigenetic effects that depend on nutrients to moderate gene expression.
Given the benefits of both nutrition therapy and MNT for individuals with diabetes, it is also important to study systematic processes within the context of health care delivery that encourage more individuals with diabetes to receive nutrition therapy initially, upon diagnosis, and long term.
Further research is also needed on the best tools and strategies for educating individuals with diabetes e. This research should include multiple settings that can impact food choices for individuals with diabetes, such as where they live, work, learn, and play.
Individuals with diabetes spend the majority of their time outside health care settings so more research on how public health, the health care system, and the community can support individuals with diabetes in their efforts to achieve healthful eating is needed. There is no standard meal plan or eating pattern that works universally for all people with diabetes 1.
Nutrition interventions should emphasize a variety of minimally processed nutrient-dense foods in appropriate portion sizes as part of a healthful eating pattern and provide the individual with diabetes with practical tools for day-to-day food plan and behavior change that can be maintained over the long term.
This position statement was written at the request of the ADA Executive Committee, which has approved the final document. The process involved extensive literature review, one face-to-face meeting of the entire writing group, one subgroup writing meeting, numerous teleconferences, and multiple revisions via e-mail communications. The authors are indebted to Sue Kirkman, MD, for her guidance and support during this process.
The two face-to-face meetings and the travel of the writing group and teleconference calls were supported by the ADA. The authors also gratefully acknowledge the following experts who provided critical review of a draft of this statement: During the past 12 months, the following relationships with companies whose products or services directly relate to the subject matter in this document are declared: No other potential conflicts of interest relevant to this article were reported.
All the named writing group authors contributed substantially to the document including researching data, contributing to discussions, writing and reviewing text, and editing the manuscript.
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We do not capture any email address. Skip to main content. Diabetes Care Jan; 37 Supplement 1: View inline View popup. Table 1 Nutrition therapy recommendations. Achieve and maintain body weight goals. Delay or prevent complications of diabetes. Diabetes nutrition therapy Ideally, the individual with diabetes should be referred to a registered dietitian RD or a similarly credentialed nutrition professional if outside of the U.
View inline View popup Download powerpoint. Effectiveness of Nutrition Therapy Nutrition therapy is recommended for all people with type 1 and type 2 diabetes as an effective component of the over all treatment plan. A Individuals who have diabetes should receive individualized MNT as needed to achieve treatment goals, preferably provided by an RD familiar with the components of diabetes MNT.
A For individuals with type 1 diabetes, participation in an intensive flexible insulin therapy education program using the carbohydrate counting meal planning approach can result in improved glycemic control. A For individuals using fixed daily insulin doses, consistent carbohydrate intake with respect to time and amount can result in improved glycemic control and reduce the risk for hypoglycemia. B A simple diabetes meal planning approach such as portion control or healthful food choices may be better suited to individuals with type 2 diabetes identified with health and numeracy literacy concerns.
B Because diabetes nutrition therapy can result in cost savings B and improved outcomes such as reduction in A1C A , nutrition therapy should be adequately reimbursed by insurance and other payers. E The common coexistence of hyperlipidemia and hypertension in people with diabetes requires monitoring of metabolic parameters e. Energy Balance For overweight or obese adults with type 2 diabetes, reducing energy intake while maintaining a healthful eating pattern is recommended to promote weight loss.
A More than three out of every four adults with diabetes are at least overweight 17 , and nearly half of individuals with diabetes are obese Optimal Mix of Macronutrients Evidence suggests that there is not an ideal percentage of calories from carbohydrate, protein, and fat for all people with diabetes B ; therefore, macronutrient distribution should be based on individualized assessment of current eating patterns, preferences, and metabolic goals.
E Although numerous studies have attempted to identify the optimal mix of macronutrients for the meal plans of people with diabetes, a systematic review 88 found that there is no ideal mix that applies broadly and that macronutrient proportions should be individualized. Eating Patterns A variety of eating patterns combinations of different foods or food groups are acceptable for the management of diabetes. E Eating patterns, also called dietary patterns, is a term used to describe combinations of different foods or food groups that characterize relationships between nutrition and health promotion and disease prevention Table 3 Reviewed eating patterns.
Individual macronutrients Carbohydrates Evidence is inconclusive for an ideal amount of carbohydrate intake for people with diabetes. C The amount of carbohydrates and available insulin may be the most important factor influencing glycemic response after eating and should be considered when developing the eating plan. A Monitoring carbohydrate intake, whether by carbohydrate counting or experience-based estimation, remains a key strategy in achieving glycemic control.
B For good health, carbohydrate intake from vegetables, fruits, whole grains, legumes, and dairy products should be advised over intake from other carbohydrate sources, especially those that contain added fats, sugars, or sodium. B Evidence is insufficient to support one specific amount of carbohydrate intake for all people with diabetes.
Quality of carbohydrates Glycemic Index and Glycemic Load Substituting low—glycemic load foods for higher—glycemic load foods may modestly improve glycemic control. C The ADA recognizes that education about glycemic index and glycemic load occurs during the development of individualized eating plans for people with diabetes.
Dietary Fiber and Whole Grains People with diabetes should consume at least the amount of fiber and whole grains recommended for the general public. C Intake of dietary fiber is associated with lower all-cause mortality , in people with diabetes. Resistant starch and fructans Resistant starch is defined as starch physically enclosed within intact cell structures as in some legumes, starch granules as in raw potato, and retrograde amylose from plants modified by plant breeding to increase amylose content.
Substitution of Sucrose for Starch While substituting sucrose-containing foods for isocaloric amounts of other carbohydrates may have similar blood glucose effects, consumption should be minimized to avoid displacing nutrient-dense food choices.
A Sucrose is a disaccharide made of glucose and fructose. C People with diabetes should limit or avoid intake of sugar-sweetened beverages SSBs from any caloric sweetener including high-fructose corn syrup and sucrose to reduce risk for weight gain and worsening of cardiometabolic risk profile.
B Fructose is a monosaccharide found naturally in fruits. Nonnutritive Sweeteners and Hypocaloric Sweeteners Use of nonnutritive sweeteners NNSs has the potential to reduce overall calorie and carbohydrate intake if substituted for caloric sweeteners without compensation by intake of additional calories from other food sources.
Protein For people with diabetes and no evidence of diabetic kidney disease, evidence is inconclusive to recommend an ideal amount of protein intake for optimizing glycemic control or improving one or more CVD risk measures; therefore, goals should be individualized. C For people with diabetes and diabetic kidney disease either micro- or macroalbuminuria , reducing the amount of dietary protein below the usual intake is not recommended because it does not alter glycemic measures, cardiovascular risk measures, or the course of glomerular filtration rate GFR decline.
A In individuals with type 2 diabetes, ingested protein appears to increase insulin response without increasing plasma glucose concentrations. Total Fat Evidence is inconclusive for an ideal amount of total fat intake for people with diabetes; therefore, goals should be individualized. B Currently, insufficient data exist to determine a defined level of total energy intake from fat at which risk of inadequacy or prevention of chronic disease occurs, so there is no adequate intake or recommended daily allowance for total fat B Evidence from large prospective cohort studies, clinical trials, and a systematic review of RCTs indicate that high-MUFA diets are associated with improved glycemic control and improved CVD risk or risk factors 70 , — Omega-3 Fatty Acids Evidence does not support recommending omega-3 EPA and DHA supplements for people with diabetes for the prevention or treatment of cardiovascular events.
A As recommended for the general public, an increase in foods containing long-chain omega-3 fatty acids EPA and DHA from fatty fish and omega-3 linolenic acid ALA is recommended for individuals with diabetes because of their beneficial effects on lipoproteins, prevention of heart disease, and associations with positive health outcomes in observational studies. B The recommendation for the general public to eat fish particularly fatty fish at least two times two servings per week is also appropriate for people with diabetes.
B The ADA systematic review identified seven RCTs and one single-arm study — using omega-3 fatty acid supplements and one cohort study on whole-food omega-3 intake. Saturated Fat, Dietary Cholesterol, and Trans Fat The amount of dietary saturated fat, cholesterol, and trans fat recommended for people with diabetes is the same as that recommended for the general population. C Few research studies have explored the relationship between the amount of SFA in the diet and glycemic control and CVD risk in people with diabetes.
Plant Stanols and Sterols Individuals with diabetes and dyslipi-demia may be able to modestly reduce total and LDL cholesterol by consuming 1. C Plant sterol and stanol esters block the intestinal absorption of dietary and biliary cholesterol 3.
Micronutrients and Herbal Supplements There is no clear evidence of benefit from vitamin or mineral supplementation in people with diabetes who do not have underlying deficiencies. C Routine supplementation with antioxidants, such as vitamins E and C and carotene, is not advised because of lack of evidence of efficacy and concern related to long-term safety. A There is insufficient evidence to support the routine use of micro-nutrients such as chromium, magnesium, and vitamin D to improve glycemic control in people with diabetes.
E There currently exists insufficient evidence of benefit from vitamin or mineral supplementation in people with or without diabetes in the absence of an underlying deficiency 3 , , Alcohol If adults with diabetes choose to drink alcohol, they should be advised to do so in moderation one drink per day or less for adult women and two drinks per day or less for adult men.
E Alcohol consumption may place people with diabetes at increased risk for delayed hypoglycemia, especially if taking insulin or insulin secretagogues. B For individuals with both diabetes and hypertension, further reduction in sodium intake should be individualized.
B Limited studies have been published on sodium reduction in people with diabetes. Clinical priorities for nutrition management for all people with diabetes A wide range of diabetes meal planning approaches or eating patterns have been shown to be clinically effective, with many including a reduced energy intake component.
Table 4 Summary of priority topics. Future research directions The evidence presented in this position statement concurs with the review previously published by Wheeler et al. For example, future studies should address: The relationships between eating patterns and disease in diverse populations. Intake of SFA and its relationship to insulin resistance. In summary There is no standard meal plan or eating pattern that works universally for all people with diabetes 1.
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