ReachMD host Dr. John Buse reviews the ideal dietary practices and lifestyle management for patients with diabetes.
Written by John Buse, M.D., Ph.D.
The Diabetic Diet: Key Considerations & Lifestyle Modifications
The “diabetic diet” is a term that we tend not to use anymore as the focus in lifestyle management of diabetes is individualized and there is technically no “diabetic diet.” I think the key components of an effective nutrition plan are first to make sure that the patient has adequate education and support in their pursuit of medical nutrition therapy. That’s generally performed best by a registered dietician, preferably one who has comprehensive knowledge and experience in diabetes care.
Lifestyle Modifications & Individualizing Diabetic Care
In patients that are overweight or obese, lifestyle modification to achieve and maintain a minimum of five percent weight loss is recommended in all patients with diabetes and pre-diabetes. There’s no single ideal dietary distribution of calories among carbohydrates, fats, and proteins for people with diabetes. Therefore, meal plans should be individualized while keeping your patients’ total calorie and metabolic goals in mind. A variety of eating patterns or, “diets,” can be considered in the management of type 2 diabetes. One of the most well-validated in outcomes trials is the Mediterranean diet.
Perhaps the most important nutrient in the setting of diabetes is carbohydrates. It is important to recognize that essentially every molecule of carbohydrates that is ingested requires the action of insulin to be cleared from the circulation. And therefore, in the setting of more advanced type 2 diabetes or type 1 diabetes, it may require more insulin therapy to achieve good glycemic control in the setting of higher carbohydrate diets. As a result, modest carbohydrate diets are preferred in the setting of diabetes. Proteins and fats are also essential nutrients. Among the fats, foods that are rich in long-chain, fatty acids, such as that that comes from fatty fish, nuts, and seeds, may be most helpful from a cardiovascular perspective. In regard to protein, high quality proteins are the key, and specifically in this setting of diabetes, protein seems to increase the insulin response without increasing glucose concentration.
Approaching Diabetic Management with a Comprehensive Diet
There’s no clear evidence that dietary supplements play an important role in diabetes management. The general recommendation around micronutrients and vitamins are that they are important and are best obtained in the diet through consumption of a wide variety of foods from all food groups. People with diabetes can drink alcohol in moderation. The important thing to understand is the association of alcohol intake with the risk of hypoglycemia, particularly in the setting of insulin use. Sodium intake can be problematic in some patients and needs to be a focus of counseling in those with fluid excess and hypertension. And finally, non-nutritive sweeteners are probably healthier than eating sugar in patients that have a sweet tooth, particularly in the context of beverages. Water is the best beverage to highlight in nutrition counseling for people with diabetes.
A top-level recommendation from prescribers, physicians, nurse practitioners, and physician’s assistants should be that the diet plan in diabetes is really important and that a dietician can help them develop a plan that works for them. Until the visit with the dietitian, being mindful of the carbohydrates, fats, and proteins in the diet is important and calorie restriction is probably the most important aspect moving forward.
Providers can start from a detailed diet history—what do you eat for breakfast, lunch, dinner, snacks and what do you drink. Clinicians can make suggestions for interval changes that are acceptable and likely to be acted upon by the patient. In an iterative process, over several visits to seduce the patient into a more healthful diet instead of trying to pigeonhole them to a particular view of a “diabetic diet” that may not fit their lifestyle and circumstances. In general, the most appropriate path is to refer the patient with diabetes to a registered dietician.