American Diabetes Association Guide to Nutrition Therapy for Diabetes. Marion J. Franz

eating pattern appears more appropriate. A healthy eating pattern includes the following: a caloric intake that attains and maintains a healthy weight for adults and appropriate weight gain in children and adolescents; foods from all food groups in nutrient-dense forms and in recommended amounts; replacement of solid fats with oils when possible; reduced intake of added sugars, refined grains (replaced with whole grains), and sodium; and if consumed, moderate alcohol intake (DGAC 2010). Intake of vegetables and fruits, whole grains, fat-free or low-fat milk and milk products, and seafood should be increased and foods containing saturated fat and trans fatty acid decreased.

      For all people with diabetes, monitoring total carbohydrate intake remains a key strategy for achieving glycemic control. Individuals on nutrition therapy alone, glucose-lowering medications, or fixed insulin doses appear to do better when carbohydrate intake is kept consistent on a day-to-day basis. Medical therapy then needs to be adjusted appropriately to cover the carbohydrate. Individuals self-adjusting their insulin doses can use insulin-to-carbohydrate ratios and correction factors (Chapter 5) to meet their glucose goals.

      There is no conclusive evidence that changing usual protein intake in people with diabetes would be beneficial. The effect of protein on glycemia depends on the state of insulinization and the degree of glycemic control. In people with well-controlled diabetes, consistent amounts of protein will have minimal acute effects on glucose or insulin.

      The ADA recommends limiting saturated fat intake to <7% of total energy intake, minimizing intake of trans fat, and limiting dietary cholesterol to <200 mg/day (ADA 2008). They note that reducing saturated fatty acids may also reduce HDL cholesterol, but importantly, the ratio of LDL cholesterol to HDL cholesterol is not adversely affected. Major sources of saturated fatty acids in the American diet include regular cheese, pizza, grain-based desserts, dairy-based desserts, chicken and chicken mixed dishes, and sausage, franks, bacon, and ribs (DGAC 2010). Saturated fatty acids can be replaced with foods containing monounsaturated and polyunsaturated fatty acids. Solid fats can be replaced with vegetable oils such as canola, olive, safflower, soybean, corn, or cottonseed oils. Synthetic trans fatty acids are found in partially hydrogenated oils used in some margarines, snack foods, and prepared desserts and should be avoided. Natural trans fatty acids are present in meat, milk, and milk products, and eliminating them is not recommended.

      In summary, 1) focus nutrition interventions on nutrition therapy strategies shown to improve metabolic outcomes—glycemia, lipids, blood pressure—and quality of life, prioritizing goals for each individual with diabetes; 2) negotiate with individuals on lifestyle changes they are willing and able to make; and, perhaps the best advice, 3) instruct patients on appropriate portion sizes of foods shown to have health benefits.

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