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Adiabetic diet is adiet that is used by people withdiabetes mellitus or high blood sugar to minimize symptoms and dangerous complications of long-term elevations in blood sugar (i.e.:cardiovascular disease,kidney disease,obesity).
Among guideline recommendations including theAmerican Diabetes Association (ADA) andDiabetes UK, there is no consensus that one specific diet is better than others.[1][2] This is due to a lack of long term high-quality studies on this subject.[1][2]
Foroverweight andobese people with diabetes, the most important aspect of any diet is that it results in loss of body fat.[1][2] Losing body fat has been proven to improve blood glucose control and lower insulin levels.[1][2]
The most agreed-upon recommendation is for the diet to be low in sugar and refined carbohydrates, while relatively high indietary fiber, especiallysoluble fiber. Likewise, people with diabetes may be encouraged to reduce their intake of carbohydrates that have a highglycemic index (GI), although theADA andDiabetes UK note that further evidence for this recommendation is needed.[3][4][1][2]
People withdiabetes can eat any food that they want, preferably ahealthy diet with somecarbohydrates, but they need to be more cognizant of the carbohydrate content of foods and avoid simple sugars like juices andsugar-sweetened beverages.[5] For people dependent on insulin injections (bothtype 1 and sometype 2 diabetics), it is helpful to eat a consistent amount of carbohydrate to make blood sugar management easier.[6]
As of 2019 there was no consensus that eating a diet consisting of any particularmacronutrient composition (i.e.: the ratio of fat, protein, and carbohydrate in the diet) is more beneficial for diabetics.[1][7] However, research on diabetic diets is limited due to the difficulty of nutritional research. These studies tend to beobservational as opposed toexperimental, relatively short in duration, and have relatively poor compliance due to the difficulty of controlling the diets of study participants at all hours of the day for extended periods of time.[8][7] Thus, more large-scale multi-center trials are needed to improve diet recommendations.[8]
Carbohydrates include sugars, starches, and fiber. These foods have the greatest impact onblood sugar levels, because after consumption they are broken down into sugars that are then absorbed by thesmall intestine.
TheAmerican Diabetes Association (ADA) does not recommend a specific amount ofcarbohydrate consumption for diabetic diets.[1] Although it is recommended to not usefructose as an added sweetener because it may adversely affect plasma lipids.[9][10] There is no minimum required amount of daily dietary carbohydrates as the body can make glucose through various metabolic processes includinggluconeogenesis andglycogenolysis.[1] The same is not true of protein and fat as both contain essential components that cannot be synthesized through human metabolism.
The ADA addresses the glycemic index and glycemic load of foods pertaining to diabetics, but they decline to make specific recommendations due to the unclear clinical utility.[1] However, meta-analyses including the most recentCochrane Systematic Review have found that a lowglycemic index diet results in better blood glucose control as measured byglycated hemoglobin A1c (HbA1c) as well as fewer hypoglycemic episodes.[3][4]
Benefits may be obtained by consumption of dietary fiber. There is some evidence that consuming dietary fiber may help control blood sugar levels; however, the ADA does not recommend any different fiber intake for diabetics than for non-diabetics.[1]
The ADA does not make a specific recommendation about the total amount of fat that should be consumed by diabetics on a daily basis.[1] They do note that studies have shown that high fat diets that have replaced carbohydrates with fat have shown improved glycemic control and improved blood lipid profiles (increased HDL concentration and decreased triglycerides) compared to low fat diets.[1] The ADA recommends avoiding all foods that have artificial sources oftrans fats but note that the small amount of trans fats that naturally occur in meat and dairy are not a concern.[1]
As at 2019 the ADA does not have a specific recommendation for dietary cholesterol intake.[1] A causal link between dietarycholesterol consumption andcardiovascular disease has not been established.[1]
Historically, there has been concern about the level of protein consumption in individuals who have diabetes induced kidney disease; however, there is no evidence that low protein diets improve kidney function.[2] There is no evidence that individuals with diabetes induced kidney disease need to restrict protein intake more than an average person's intake.[2]
For type 1 diabetics, there is a lack of definitive evidence of the usefulness oflow-carbohydrate diets due to limited study of this topic.[1][11][12] Ameta-analysis published in 2018 found only nine papers that had adequately studied the implementation of low carbohydrate diets in type 1 diabetics as of March 2017.[12] This review found that low carbohydrate diets consistently reducedinsulin requirements but found inconsistent results in regard to the diet's effect on blood glucose levels.[12] 3 studies found significant decreases inHbA1c on low carbohydrate diets while 5 found that HbA1c levels were stable.[12] This review as well as the ADA consensus statement suggests that low carbohydrate diets may be beneficial for type 1 diabetics but largerclinical trials are needed for further evidence.[1][12]
A low-carbohydrate diet gives slightly better control of glucose metabolism than a low-fat diet in type 2 diabetes.[13][14] In a 2019 consensus report on nutrition therapy for adults with diabetes and prediabetes theAmerican Diabetes Association (ADA) states "Reducing overall carbohydrate intake for individuals with diabetes has demonstrated the most evidence for improving glycemia (blood sugar) and may be applied in a variety of eating patterns that meet individual needs and preferences.", it also states that reducing overall carbohydrate intake with low- or very low- carbohydrate eating plans is a viable approach.[15] In fact, some investigations say that patients adhering to an low carbohydrate diet may experience remission of diabetes type 2 without adverse consequences[16][17]
The ADA say low-carbohydrate diets can be useful to help people with type 2 diabetes lose weight, but that these diets were poorly defined, difficult to sustain, unsuitable for certain groups of people and that, for diet composition in general".[18] Overall, the ADA recommends people with diabetes develop "healthy eating patterns rather than focusing on individual macronutrients, micronutrients, or single foods". They recommend that carbohydrates in a diet should come fromwhole food sources such as "vegetables,legumes, fruits, dairy (milk and yogurt), and whole grains"; highly refined foods and sugary drinks should be avoided.[18]
Althoughvegan andvegetarian diets can vary greatly in the type of food consumed as well as the macronutrient profile of the diet, they are often lumped together in the context of the scientific literature since they are both consideredplant-based diets. Like any other diet's impact on diabetes, the most important factor is the resulting loss of overall fat mass.[1][2] Both vegan and vegetarian diets have been shown to be beneficial for weight loss in comparison to thestandard American diet.[1][19] For type 2 diabetics, the focus of a vegetarian or vegan diet should be maintaining a level of caloric intake that results in fat loss, adequate protein consumption, adequate consumption of compounds that are mostbio-available in animal products (i.e.vitamin B-12,iron,creatine), andwhole food carbohydrate sources that are lower in glycemic index.
TheAcademy of Nutrition and Dietetics maintains that well formulated vegetarian and vegan diets can be healthy and nutritionally adequate for people of all ages.[20] TheAmerican Diabetes Association notes that the use of vegetarian or vegan diets for diabetes have had inconclusive results in the literature.[1] Two meta-analyses showed small improvements in HbA1C; whereas, one of the two found that the diets resulted in weight loss and improvement in cardiovascular risk factors.[1]
Lowering theglycemic index of one's diet may improve the control of diabetes.[21][22] This includes avoidance of such foods as potatoes cooked in certain ways (i.e.: boiled and mashed potatoes are higherGI than fried) and bread.[23] Lower glycemic index carbohydrate sources include vegetables, legumes, and whole grains that contain higher fiber content and are digested and absorbed into the blood stream more slowly than refined carbohydrates.
TheADA recommends a level of fiber intake consistent with theDietary Guidelines for Americans 2015–2020 (minimum of 14 g of fiber per 1,000 kcal).[1][24] However, there is some evidence that higher intakes (daily consumption of 50g of fiber and higher), can result in small improvements in blood sugar levels.[25][26][27][28] The ADA cautions that higher intakes may cause digestive issues such as "flatulence, bloating, and diarrhea."[1]
For people with diabetes, healthy eating is not simply a matter ofwhat one eats, but alsowhen one eats. For insulin dependent diabetics, when they eat depends on their blood sugar level and the type of insulin they take (i.e.: long-, medium- or quick-acting insulin). If patients check theirblood glucose at bedtime and find that it is low, for example below 6millimoles per liter (108 mg/dL), it is advisable that they take some long-acting carbohydrate before retiring to bed to prevent night-timehypoglycemia.[citation needed]Night sweats,headaches, restless sleep, andnightmares can be a sign of nocturnalhypoglycemia, and patients should consult their doctor for adjustments to their insulin routine if they find that this is the case.[29] Another possible sign of nocturnal hypoglycemia is morning hyperglycemia, which actually occurs in response to blood sugar getting too low at night. This is called theSomogyi effect.
In relation to type 2 diabetes, eating most food earlier in the day may be associated with lower levels of overweight, obesity and other factors that reduce the risk of developing type 2 diabetes.[30] TheADA notes that several studies have shown benefit ofintermittent fasting on blood sugar control.[1] However, these studies were relatively small and short in duration and further study is warranted.[1] There were also different protocols for fasting which makes comparisons across studies more difficult.[1]
Diabetes UK have warned against purchase of products that are specially made for people with diabetes, on grounds that:[31]
NICE (the National Institute for Health and Clinical Excellence in theUnited Kingdom) advises doctors and other health professionals to "Discourage the use of foods marketed specifically for people with diabetes".[32]
TheADA recommends that people with diabetes limit alcohol consumption as recommended by theDietary Guidelines for Americans (up to one drink per day for women and up to two drinks per day for men).[1][24] Consumption of alcohol above this amount may lead toelevation in blood sugar.[1] Consumption of alcohol also puts diabetics at increased risk ofhypoglycemia.[1] The ADA states that this may be due to the "inhibition ofgluconeogenesis, reduced hypoglycemia awareness due to the cerebral effects of alcohol, and/or impaired counterregulatory responses to hypoglycemia."[1] This puts diabetics who take insulin or otheranti-hyperglycemics at risk of night time or fasting hypoglycemia.[1] Consuming food with alcohol reduces this risk of hypoglycemia.[1]
There has been a long history of dietary treatment ofdiabetes mellitus. Dietary treatment of diabetes mellitus was used in Egypt since 3,500 BC[33] and was used in India bySushruta andCharaka more than 2000 years ago.[33] In the 18th century, the Scottish surgeonJohn Rollo argued that calorie restriction could reduceglycosuria in diabetes.[33]
More modern history of the diabetic diet may begin withFrederick Madison Allen andElliott Joslin, who, in the early 20th century, beforeinsulin was discovered, recommended that people with diabetes eat only a low-calorie and nearly zero-carbohydrate diet to preventketoacidosis from killing them. While this approach could extend life by a limited period, patients developed a variety of other medical problems.[34]
The introduction of insulin byFrederick Banting in 1922 allowed patients more flexibility in their eating.[34]
In the 1950s, theAmerican Diabetes Association, in conjunction with theU.S. Public Health Service, introduced the "exchange scheme". This allowed people to swap foods of similar nutrition value (e.g., carbohydrate) for another. For example, if wishing to have more than normal carbohydrates for dessert, one could cut back on potatoes in one's first course. The exchange scheme was revised in 1976, 1986, and 1995.[35]
Not all diabetesdietitians today recommend the exchange scheme. Instead, they are likely to recommend a typical healthy diet: one high in fiber, with a variety of fruit and vegetables, and low in both sugar and fat, especiallysaturated fat.
A diet high in plant fibre was recommended by James Anderson.[36] This may be understood as continuation of the work ofDenis Burkitt andHugh Trowell on dietary fibre,[37] which may be understood as a continuation of the work of Price.[38] It is still recommended that people with diabetes consume a diet that is high indietary fiber.
In 1976,Nathan Pritikin opened a centre where patients were put on programme of diet and exercise (thePritikin Program). This diet is high on carbohydrates and fibre, with fresh fruit, vegetables, and whole grains. A study atUCLA in 2005 showed that it brought dramatic improvement to a group of people with diabetes or pre-diabetes in three weeks, so that about half no longer met the criteria for the disease.[39][40][41][42]
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