Guidelines for the

Nutritional Management
of Diabetes Mellitus in
the New Millennium
A POSITION STATEMENT
08/9904210M

BY THE CANADIAN DIABETES ASSOCIATION

Reprinted from Canadian Journal of Diabetes Care 23(3): 5669.
#416510
 CONTENTS

INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
General principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Nutritional goals of diabetes management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
ENERGY NUTRIENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Carbohydrates. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Sugars . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Fibre . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Protein. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Fats . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Alcohol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Sweeteners . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
MICRONUTRIENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
LIFE STAGES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Infants, children and teenagers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Elderly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
LIFESTYLE/CULTURE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Frequency of eating. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Exercise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Vegetarian eating. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Travel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Cultural sensitivity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
OTHER CONSIDERATIONS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Weight management and obesity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Dyslipidemia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Nephropathy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Neuropathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Considerations for insulin and/or insulin secretagogue users . . . . . . . . . . . . . . . . . . . . . . . 11
Hypoglycemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Weight. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Carbohydrate counting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
New and future diabetes medications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
PREVENTION OF TYPE 2 DIABETES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
ACKNOWLEDGMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Steering Committee Members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Expert Committee Members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
 POSITION PAPER 3

GUIDELINES FOR THE NUTRITIONAL

MANAGEMENT OF DIABETES MELLITUS IN
THE NEW MILLENNIUM: A POSITION STATEMENT
BY THE CANADIAN DIABETES ASSOCIATION
Thomas Wolever MD PhD, Marie-Claire Barbeau DtP, Stephanie Charron PHEc, Kathy Harrigan PDt MHE CDE,
Sharon Leung RDN CDE, Bev Madrick RD CDE, Teresa Taillefer RD CDE, Carol Seto RD CDE
National Nutrition Committee, Canadian Diabetes Association

INTRODUCTION
The overall goal of diabetes management is to help People with diabetes can continue to enjoy the foods
individuals with diabetes and their families gain the nec- they love, in moderation, while maintaining the variety
essary knowledge, life skills, resources and support needed promoted by Canadas Food Guide to Healthy Eating.
to achieve optimal health. This requires a team effort If medication is necessary to optimize diabetes control, its
that includes diabetes health care professionals and the use should be an adjunct to regular physical activity and
individuals who must deal with this chronic condition on healthy eating. The timing and doses of medication used
a daily basis. The registered dietitian is a key member of should be adjusted to fit with the eating and physical
the health care team, who plays an integral role in the activity patterns chosen by the individual with diabetes.
individualization of management strategies for people
with diabetes and those at risk for developing it. The Nutritional goals of diabetes management
nutritional management of diabetes follows the principles A major goal for diabetes care is to improve glycemic
of Canadas Food Guide to Healthy Eating (1) and remains control by balancing food intake with endogenous and/or
one of the cornerstones of effective therapy. exogenous insulin levels. For people with type 1 diabetes,
Nutritional management seeks to improve or maintain insulin doses need to be adjusted to balance with nutri-
the following: tionally adequate food intake and physical activity. For
the quality of life for people with diabetes and their individuals with type 2 diabetes, impaired glucose toler-
families through management techniques that include ance or impaired fasting glucose, attention to food portions
the entire family unit in decision-making, while and weight management combined with physical activity
enhancing the individuals personal sense of control and may help improve glycemic control. Nutrition and all
well-being; forms of diabetes management should be individualized.
the physiological health of individuals with diabetes,
by establishing and maintaining blood glucose and Recommendations
lipid levels as near-normal as possible, and by using All people with diabetes should receive nutritional
vigilance in preventing and/or treating diabetes-related counselling from a registered dietitian.
complications and any concomitant conditions; and Canadas Guidelines for Healthy Eating and Canadas Food
the nutritional status of people with diabetes, by Guide to Healthy Eating should be equally applied to
recognizing that their micro- and macronutrient people with diabetes and without diabetes.
requirements are similar to those of the general People with diabetes should be encouraged to obtain
population. optimal metabolic control through a balance of food
intake, physical activity and medication (if required) to
General principles avoid complications (3,4).
In general, nutrition advice for people with diabetes Specific dietary recommendations and medications
is the same as that for all Canadians, and follows the should be individualized to accommodate the persons
principles of Canadas Guidelines for Healthy Eating (2): preferences and lifestyle.
Enjoy a variety of foods.
Emphasize cereals, breads and other whole grain ENERGY NUTRIENTS
products, vegetables and fruits. Carbohydrates
Choose lower-fat dairy products, leaner meats and Dietary carbohydrates from cereals, breads, other grain
foods prepared with little or no fat. products, legumes, vegetables, fruits, dairy products and
Achieve and maintain a healthy body weight by added sugars should provide 5060% of the individuals
enjoying regular physical activity and healthy eating. energy requirements (5). Both the source and the amount
Limit salt, alcohol and caffeine. of carbohydrate consumed influence blood glucose and
insulin responses (6,7).The terms simple and complex
4

should not be used to classify carbohydrates, because they slightly earlier but fall more quickly than consuming an
do not help to determine the impact of carbohydrates on equivalent carbohydrate portion of white bread.This results
blood glucose levels (8,9). Factors that influence blood in a lower GI for fruits and fruit juices than bread (9,23).
glucose are not predicted by chemical composition alone; Because refined sucrose produces a lower blood glucose
food form, ingested particle size, starch structure and response than many refined starches, some sweetened
cooking methods may all influence the carbohydrate breakfast cereals produce lower plasma glucose and insulin
absorption rate from the small intestine and the resultant responses than equal carbohydrate portions of unsweetened
blood glucose response (10). cereals (24). Thus, undue avoidance of foods containing
The glycemic index (GI) expresses the rise in blood simple sugars is not necessary. Generally, however, intake of
glucose elicited by a carbohydrate food as a percentage of added fructose, sucrose or high-fructose corn syrup in
the rise in blood glucose that would occur if the same excess of 10% of energy should be avoided, since evidence
individual ingested an equal amount of carbohydrate from suggests that this may increase serum triglycerides and/or
white bread or glucose (8,11). Increased use of low GI LDL cholesterol in susceptible individuals (25).
foods such as legumes, barley, pasta and whole intact grains
(e.g. cracked wheat) may help improve blood glucose Recommendations
control and allow carbohydrate intake to be increased Naturally occurring and added sugars should be
without raising serum triglycerides (12). included as part of the daily carbohydrate allowance
The role of the GI in diabetes therapy is controversial. and as part of a healthy eating plan.
The GI is not endorsed by the American Diabetes Most people with diabetes can include added sugars
Association (13), but it is recommended by the up to 10% of daily energy requirements without
Diabetes Nutrition Study Group of the European deleterious effects on blood glucose or lipid control.
Association for the Study of Diabetes (14) and by the
World Health Organization (8). There is concern that Fibre
including GI information in nutrition teaching is too Daily soluble fibre intake of 510 g/d from oats, barley,
complicated and limits food choices (15). Nevertheless, legumes or purified fibre sources such as psyllium, pectin
in people with newly diagnosed type 2 diabetes, there is and guar, can reduce serum cholesterol by 510% (26,27).
evidence that nutrition education based on the GI is asso- Purified soluble fibre sources reduce blood glucose respons-
ciated with higher carbohydrate, lower fat and higher es and have been associated with improved blood glucose
fibre intakes as well as better blood glucose and lipid control (28). However, soluble fibre content alone is not a
control compared to those educated using traditional reliable indicator of the foods metabolic effects. Research
dietary advice (16). Epidemiological studies also suggest indicates that the insoluble fibre content of whole foods is
that use of low GI foods reduces the risk of developing more closely related to their GI than the soluble fibre
type 2 diabetes (17,18). Extensive tables of the GI values of content (29). This is consistent with data from epidemio-
foods have been published (19). logical studies, which suggest that insoluble fibres from
cereals may reduce the risk for coronary heart disease and
Recommendations type 2 diabetes by up to 30% for each 10 g increment in
Carbohydrates should provide 5060% of daily energy intake (17,18,30).All Canadians, including people with dia-
requirements. betes, are advised to increase fibre intake from a variety of
The amount and source of carbohydrate in meal foods by following Canadas Food Guide to Healthy Eating.
planning should be considered.
Including low GI foods may be helpful in optimizing Recommendations
blood glucose control. Total dietary fibre intake of at least 2535 g/d from a
variety of sources, as recommended by Canadas Food
Sugars Guide to Healthy Eating, is advised for adults. For
In the past, avoidance of sugar has been a major focus of children, 5 g plus 1 g/year of age is suggested as a guide.
nutritional advice for people with diabetes. However, Including more foods and food combinations that
research clearly shows that sugars are an acceptable part of combine cereal fibre with low GI may be helpful in
a healthy diet for those with diabetes, particularly sugars optimizing health outcomes for people with diabetes
obtained from fruits, vegetables and dairy products. Up to or at risk for diabetes.
10% of total daily energy requirements may consist of
added sugars, such as table sugar and sugar-sweetened Protein
products, without impairing glycemic control in people Current evidence indicates people with diabetes have
with type 1 (20) or type 2 (21,22) diabetes. similar protein requirements to those of the general
Foods containing sugars vary in nutritional value and population about 0.86 g/kg per day (5). Although
physiological effects. For example, sucrose and orange juice protein plays a role in stimulating insulin secretion (31,32),
have similar effects on blood glucose but contain different excessive intake should be avoided as it may contribute to
amounts of vitamins and minerals. Consuming whole fruits the pathogenesis of diabetic nephropathy (33). Some evi-
and fruit juices causes blood glucose concentrations to peak dence suggests eating vegetable protein rather than animal
 POSITION PAPER 5

protein is better for reducing serum cholesterol (34) and are well controlled. Intake should account for no more than
managing nephropathy (35,36). 5% of total energy intake or 2 drinks per day, whichever is
less. Abstinence is recommended during pregnancy and
Recommendations lactation. Restriction or avoidance of alcohol may also be
Protein intake should be at least 0.86 g/kg/day. advisable for people with concomitant medical conditions
Vegetable protein should be considered as an alterna- such as dyslipidemia, hypertension or liver impairment.
tive to animal protein. Regular alcohol intake can contribute to weight gain and
both hypoglycemia and hyperglycemia. Guidelines on the
Fats use of alcohol should be included as part of meal-planning
Numerous studies indicate high-fat diets can impair discussions.
glucose tolerance and promote obesity, dyslipidemia and Alcohol impairs hepatic glucose release and can
atherosclerotic heart disease. Research also shows these cause delayed hypoglycemia in individuals taking insulin
same metabolic abnormalities are reversed or improved and/or insulin secretagogues.Increased physical activity and/or
by reducing saturated fat intake. Current recommenda- reduced food intake in the presence of alcohol intake can
tions on fat intake for the general population apply further increase the risk of hypoglycemia. To reduce this
equally to people with diabetes: reduce saturated fats risk, individuals on these medications would be advised to
to 10% or less of total energy intake and cholesterol consume foods containing carbohydrate when drinking
intake to 300 mg/d or less (37). Scientific debate alcohol. Family members and other support people
continues over which alternative is preferable to saturated should understand the relationship between alcohol and
fat polyunsaturated fat, monounsaturated fat or diabetes and how to manage short-term consequences.
carbohydrate calories (38,39). People with diabetes should be encouraged to wear
Health Canadas nutrition guidelines are still considered medical alert bracelets, to ensure prompt identification and
appropriate for most people with diabetes. For adults who treatment of their condition in emergency situations.
have normal lipid levels and maintain a reasonable weight,
the guidelines recommend a daily fat intake 30% of daily Recommendations
energy requirements, comprised of 10% saturated fat People with diabetes should discuss alcohol use with
and 10% polyunsaturated fat, with the remainder their health care team.
coming from monounsaturated fat (5). Alcohol consumption should be limited to 5% of total
Research suggests monounsaturated fat (such as canola, energy intake or 2 drinks per day, whichever is less.
olive and peanut oils) may have beneficial effects on People with diabetes using insulin and/or insulin
triglycerides and glycemic control in some individuals secretagogues, should eat a carbohydrate food when
with diabetes (40), but care must be taken to avoid weight drinking alcohol to help avoid hypoglycemia.
gain. Omega-3 fatty acids, found in fish such as salmon Abstinence from alcohol is advised during pregnancy
and mackerel, may reduce serum triglycerides without and lactation.
impairing glycemic control (41). Although consuming Individuals with medical conditions such as dyslipi-
large quantities of omega-3 fatty acids from natural foods demia, hypertension or liver impairment should avoid
is probably not practical for most, eating fish rich in or restrict alcohol consumption.
omega-3 fatty acids at least once weekly is recommend-
ed. Conversely, ingesting trans-fatty acids that are Sweeteners
commonly found in many manufactured foods should be Moderate use of nutritive (sucrose, fructose, the sugar
limited. Produced by hydrogenating vegetable oils, the alcohols [xylitol, mannitol, sorbitol, isomalt, lactitol and
biological effects of trans-fatty acids are similar to those of maltitol] and aspartame) and non-nutritive sweeteners
saturated fat (42,43). (acesulfame potassium, sucralose, cyclamate and saccharin)
can be part of a well-balanced diet for people with
Recommendations diabetes (44).The energy and/or carbohydrate content of
Total fat should be limited to 30% of daily energy nutritive sweeteners needs to be included in the meal plan,
requirements. whereas non-nutritive sweeteners do not affect blood
Saturated and polyunsaturated fats should each provide glucose levels and provide little or no energy. For example,
10% of daily energy requirements. aspartame is a nutritive sweetener. It provides 16 kJ/g but
Monounsaturated fats should be used where possible. has a minimal energy contribution to the diet because it is
Use of processed foods containing saturated fats and extremely sweet (180200 times sweeter than sucrose),
trans-fatty acids should be limited. so only a very small amount is required to sweeten a
Fish rich in omega-3 fatty acids should be recom- food product. Sugar alcohols raise blood glucose only
mended at least once weekly. minimally (45,46) and contribute a small amount of energy
to the diet. Sugar alcohols are absorbed and metabolized at
Alcohol different rates in the small intestine and can cause flatulence
Moderate alcohol consumption is acceptable for and diarrhea in some individuals (47).
individuals with diabetes whose blood glucose and lipids During pregnancy and lactation, saccharin and cyclamate
6

are not recommended. In moderation, acesulfame potassi- Table 1

um, aspartame and sucralose (48) are acceptable. In
individuals with phenylketonuria, the use of aspartame is Sweeteners
contraindicated.
In Canada, nutritive and non-nutritive sweeteners are Acceptable daily intake
regulated as food additives. Health Canada sets standards (mg/kg body weight/day)
that regulate the amount of food additives that are
permitted for use in foods.Table 1 provides the acceptable Aspartame 40 Saccharin 15
daily intake (ADI) for some common sweeteners. The Acesulfame K 15 Sucralose* 15
ADI is expressed in mg/kg of body weight per day and is Cyclamate 11
defined as the amount of sweetener that can be safely
consumed on a daily basis over a persons lifetime without *Canada has a more conservative ADI of 9 mg/kg body weight/day
any adverse effects. The ADI amounts are actually much Ref.: 1996 FAO/WHO Joint Expert Committee Food
higher than the amounts an individual would consume in Additives publication.
a typical diet. However, individuals with diabetes should
receive individualized counselling on how to include the Decreased magnesium stores are correlated with poor
use of foods containing sweeteners. These foods are often diabetic control, insulin resistance, macrovascular disease
not low in energy due to the fat content of the product. and hypertension (51), but the low magnesium status may
Individuals should therefore be advised on how to evaluate be the result rather than the cause of these conditions.
food labels for total fat and sweetener content and on how There is insufficient evidence that magnesium supplements
to substitute these products for other food choices within improve blood glucose control. Chromium deficiency can
the meal plan. Individuals should also monitor blood result in decreased glucose tolerance but is believed to be
glucose and lipid levels on a regular basis and assess their rare (52). Most studies have not shown any benefit from
response to routine sweetener use. chromium supplements, possibly because of inadequate
doses or the use of poorly absorbed forms of the mineral
Recommendations (53). A recent study showed that chromium picolinate
Individuals with diabetes should be educated on significantly improved glycemic control in people with
the appropriate use of nutritive and non-nutritive diabetes (54). However, the doses used, 3.84 and 19.2 mol
sweeteners. (200 and 1,000 g of elemental chromium) per day,
The impact of nutritive sweeteners on the individuals were higher than the upper limit of the estimated safe and
blood glucose levels and lipid profiles should be assessed adequate daily intake.
on a regular basis.
Recommendations
MICRONUTRIENTS People with diabetes should be encouraged to obtain
People with diabetes should be encouraged to obtain daily vitamin and mineral requirements from a well-
daily vitamin and mineral requirements from a well- balanced diet.
balanced diet. Routine use of vitamin/mineral supplements Routine use of vitamin or mineral supplements is not
is not recommended except in cases of inadequate food recommended except in cases of inadequate food
consumption or other special needs. Despite various consumption or other special needs.
claims concerning the benefits of supplements of vitamins
and minerals in the treatment of diabetes, the evidence LIFE STAGES
is not sufficient at this time to recommend routine Infants, children and teenagers
supplementation. Adequate nutrition should be provided to support the
People with diabetes have reduced antioxidant capacity, growth, development and normal activity of all children
and this may play a role in the development of complica- with diabetes. Protein requirements for children with
tions by increasing protein glycosylation, increasing the diabetes are higher than those of adults but are no differ-
atherogenic potential of serum LDL particles and altering ent than for children without diabetes (5). Fat restriction
endothelial function (49). Short-term increases in plasma ( 30% total energy) is contraindicated in infants and
antioxidant capacity can be demonstrated after consump- young children less than 2 years of age (55). Avoiding
tion of antioxidant vitamins such as b-carotene or vitamins hypoglycemia is the primary goal of diabetes management
C or E. However, the long-term implications of this are not in this population (56). Variable carbohydrate intake in
clear. The Microalbuminuria, Cardiovascular and Renal this group can make it difficult to predict insulin doses.
Outcomes of the Heart Outcomes Prevention Evaluation Fast-acting insulin analogues can be useful in this situation
(MICRO-HOPE) study involves 3,657 subjects with since they may be given after meals based on the amount
diabetes randomized to receive ACE inhibitor or placebo of carbohydrate eaten. Meals and snacks should be planned
and vitamin E or placebo for 4 years (50). The results of around the childs individual routine, and frequent follow-
this study, expected next year, will be helpful in determin- up is recommended so the nutritional plan can be adjusted
ing the role of vitamin E in the treatment of diabetes. to meet the growing childs energy needs.
 POSITION PAPER 7

Most children with type 1 diabetes have normal lipid 1.0 mg of folic acid. This supplement is recommended
levels and acceptable weights but are at significant risk of before pregnancy and during the early weeks of pregnan-
developing long-term macrovascular disease (57).This risk cy to ensure that folic acid requirements are met (70).
is increased by adoption of lifestyle factors such as excess Control of blood glucose and supplementation of folic
energy intake, diets high in saturated fats, low physical acid are both promoted to reduce the risk of congenital
activity and smoking. Lifestyle education and counselling malformations in the offspring of women with type 1
on avoiding these risks can prevent or delay the develop- and 2 diabetes. Screening of all pregnant women (except
ment of cardiovascular disease later in life. There has been those at very low risk) at 2428 weeks is recommended to
an increase in the diagnoses of children with type 2 diagnose and treat gestational diabetes mellitus (71).
diabetes, especially in ethnic populations in Canada. It is important that the woman with diabetes have follow-
Diabetes resources should be made available to families with up visits with a health care team experienced in
children who have type 1 or type 2 diabetes. Bridging prenatal care. A registered dietitians role is to promote a
programs should be implemented to facilitate the transition healthy diet that meets the micro- and macronutrient
from adolescence to adulthood. needs of pregnancy. Food choices are often divided into 6
Weight gain following initiation of insulin therapy small meals spread at regular intervals throughout the day and
and focus on dietary restraint may lead to body-image evening.This small, frequent meal pattern may help reduce
dissatisfaction and weight concerns already common in prenatal complaints such as nausea and heartburn while
adolescence, therefore predisposing a child to disordered reducing the risk of hypoglycemia and ketonuria.This strat-
eating (5861). Clinical warning signs to identify egy appears to reduce acute peak glycemia excursions
individuals at risk of eating disorders include refractory (72,73), which may avoid the need for adjustments to insulin
metabolic control, weight occupation and anxiety about dosage. However, more research is required to establish
being weighed, and delay in puberty, sexual maturation or whether increasing meal frequency reliably improves overall
growth (58,6266). It is recommended that screening for glycemic control in diabetes or alters pregnancy outcome.
behaviours/attitudes associated with disordered eating (i.e. Tools such as daily food/activity records, morning ketone
excessive physical activity, restrictive eating, insulin misuse testing, daily self blood glucose monitoring and regular
and body-image dissatisfaction) be incorporated into weight gain monitoring will help the registered dietitian
follow-up visits (58,61,64,6769). further individualize the nutrition care plan with the expec-
tant mother. Pregnancy-specific issues such as the safety of
Recommendations medications, use of nutritive and non-nutritive sweeteners,
Avoiding hypoglycemia should be the primary goal of treatment of nausea and appropriate physical activity should
diabetes management in infants and children. be discussed on an individual basis. Insulin requirements
All children should be assessed at least annually by a increase in pregnancy and may require that adjustments be
registered dietitian specializing in pediatric nutrition to made to insulin dosage.The use of insulin secretagogues in
ensure they are receiving adequate nutrition for growth pregnancy is contraindicated (74,75).Breastfeeding should be
and development. promoted during pregnancy; women with diabetes need to
Parents and caregivers of children with diabetes should understand that they can successfully breastfeed their off-
be alert for unpredictable carbohydrate intake that may spring and that they are aware of resources available to them.
require adjustment to the type, timing and dose of During the early weeks of the postpartum period,
insulin. mothers with diabetes should continue to check their
Fat restriction is contraindicated in infants and young blood glucose regularly. It is important that women with
children less than 2 years of age. gestational diabetes understand that they are at risk of devel-
Lifestyle and smoking avoidance education are recom- oping subsequent diabetes and that they should be tested
mended to reduce the long-term risks of vascular again between 6 weeks and 6 months postpartum. Lifestyle
disease. issues such as healthy eating habits and regular physical
Follow-up visits should incorporate routine screening activity to achieve a healthy body weight should be encour-
for behaviours and attitudes associated with disordered aged. For breastfeeding women, ensure that energy
eating. requirements are met. Breastfeeding women requiring
Bridging programs should be used to assist transitions insulin may need to adjust their dose based on self blood
from adolescence to adulthood. glucose monitoring results (76). It is important to protect
the infant from the risk of maternal hypoglycemia by
Pregnancy ensuring that food is handy to treat low blood glucose.
Achieving normoglycemia while consuming a nutri- Hypoglycemia is often related to a late meal or snack rather
tionally adequate diet is the goal for women who enter than due to the energy expended by the feeding (76).As the
pregnancy with pre-existing diabetes and for those who infant is weaned off breast milk, women with diabetes will
develop diabetes while pregnant. Preconception coun- have to continue to monitor their weight, energy intake,
selling is recommended to promote these goals and to medication and blood glucose levels to achieve goals set
initiate a multivitamin supplement that contains 0.4 mg to with the health care team.
8

Recommendations peak glycemic excursions that can occur by ingesting

All mothers with diabetes should have follow-up visits carbohydrate in 3 large meals spaced 45 hours apart (79).
with a registered dietitian to ensure that the diet is This strategy may be useful in certain circumstances, such
well-balanced and individualized with the goal of as gestational diabetes. However, there is no evidence that
achieving normal maternal glucose levels. increased meal frequency (changing from 3 to 9 meals per
A multivitamin with 0.4 mg to 1.0 mg folic acid day) leads to long-term improvement in glycemic control
prior to conception and during the early weeks of (80). The consumption of small, equal-sized, frequent
pregnancy is recommended to reduce the risk of neural meals, with no increase in energy intake, may be difficult
tube defects and congenital malformations in the off- to achieve in the long term because the size and timing of
spring of the mother with diabetes. meals is determined by a multitude of chronobiological,
Breastfeeding should be promoted prenatally to ensure physiological, psychological, social and cultural factors (81).
that women with diabetes know how to deal with the Consequently, there is no one ideal food distribution
glycemic effects of breastfeeding. pattern that can be universally recommended.
Women with gestational diabetes should be informed
of their increased risk for type 2 diabetes and the Recommendation
importance of adopting a healthy lifestyle. The person with diabetes and the health care team
should determine appropriate meal intervals.
Elderly
Nutrition management for older persons with diabetes Exercise
is essentially the same as for older adults without dia- The multiple health benefits and improved sense of well-
betes. When developing a meal plan, it is important to being that physical activity provides are well known (82,83).
consider the presence of co-existing conditions and the For people with type 2 diabetes, increasing physical
individuals social situation, including finances and the activity can also increase insulin sensitivity, thereby improv-
ability to shop and cook.Hypoglycemia is a serious concern ing glycemic control.This may lessen or eliminate the need
among older people with diabetes who take insulin and/or for medication (82). People with type 1 diabetes can also
insulin secretagogues for their diabetes, since many have enjoy the benefits of physical activity, although the effect on
reduced awareness of symptoms (77). Meal planning should glycemic control will vary among individuals (83).
therefore consider the risk of hypoglycemia in older persons Physical activity can also benefit the person with diabetes
taking diabetes medication. Because of a reduced thirst by aiding in weight loss. Weight loss in itself can often
mechanism in the older person, adequate fluid intake must decrease blood glucose. However, regardless of weight loss,
be ensured to avoid dehydration and constipation. Dietary physical activity may require the adjustment of insulin
approaches to prevent constipation in the older person with and/or insulin secretagogues as well as carbohydrate intake
diabetes are encouraged. Pharmaceutical and physical inter- depending on the persons weight goal and personal choice.
ventions to treat constipation should be used as a last resort. For example, for people attempting weight loss by initiat-
Regular follow-up visits to the health care team can help ing or increasing physical activity, diabetes medications
promote adequate energy, protein and micronutrients in may need to be decreased to avoid hypoglycemia, since
their diet, while maintaining a good quality of life. increasing food intake would be counter-productive.Those
requiring diabetes medications must also be aware that
Recommendations the glucose-lowering effects of physical activity can last or
Nutrition plans for older persons with diabetes occur up to 1224 hours or more after the activity. Thus,
should be the same as for other adults with diabetes but medications and/or food intake may need to be adjusted
may need adjustment due to co-existing conditions and after physical activity, not just before it. Frequent blood
social situation. glucose monitoring should aid any adjustments.
Meal planning should consider the risk of hypo- Individual tolerance of physical activity, concomitant
glycemia in individuals on insulin and/or insulin physical or medical conditions and diabetes control should
secretagogues. be assessed prior to the health care team recommending
Dietary approaches for the treatment of constipation an appropriate program of physical activity (84). Canadas
should be attempted in older persons with diabetes. Physical Activity Guide to Healthy Active Living (85) can serve
Periodic nutritional assessments are advised to ensure as a reference for those with uncomplicated diabetes and
adequate intake of energy, protein, micronutrients and no other medical conditions.
maintenance of quality of life.
Recommendations
LIFESTYLE/CULTURE People with diabetes should consult with the diabetes
Frequency of eating health care team when considering a change to their
There is evidence that dividing carbohydrate portions level of physical activity.
into 9 or more equal meals spaced throughout the day Plans for physical activity should be individualized for
reduces serum cholesterol (78) and will acutely reduce the all people with diabetes.
 POSITION PAPER 9

Medication and/or food may need to be adjusted to Cultural sensitivity

avoid hypoglycemia while meeting individual body When conducting nutritional assessments and providing
weight goals. nutritional advice, the registered dietitian takes into account
many variables in the hope of positively influencing behav-
Vegetarian eating iour and health outcomes. In addition to health beliefs,
A well-balanced vegetarian diet can be a healthy decision-making skills, financial resources, food availability
choice for people with diabetes.Vegetarian diets empha- and personal choice, foods chosen by people with diabetes
size fibre-rich grains and vegetable proteins, both of are often influenced by their cultural heritage.To facilitate
which have been associated with lowering cholesterol adherence, knowledge of culturally and individually accept-
levels and cardiovascular risk (8688). Nutritional evalu- able foods will assist the registered dietitian in planning
ations of protein, iron, calcium, vitamin B12, vitamin D meals with the individual with diabetes (93,94).
and overall daily energy intake are recommended. Special Special attention must be provided to Aboriginal people,
attention is needed in planning vegan diets for children, because type 2 diabetes is now recognized as a major health
older adults, pregnant or lactating women, and ill problem in this population. Over the past 50 years, dramat-
people with diabetes (89,90). A registered dietitian can ic changes in lifestyle in Aboriginal communities across
assist these groups in the planning of nutritionally North America have affected the social, environmental
adequate meals. and health status of this population (71). Aboriginal diets
vary greatly throughout the country. Aboriginal people
Recommendations in remote northern communities have vastly different
A well-balanced vegetarian diet can be considered lifestyles than those living in urban centres. In general, there
as a healthy choice for people with diabetes. is more consumption of supermarket foods and less
A registered dietitian should be consulted to help plan reliance on once-traditional foods (95). Many Aboriginal
nutritionally adequate meals, especially in children, health authorities believe that the use of non-traditional
older adults, pregnant or lactating women, and ill people foods and the prevalence of sedentary lifestyles may be con-
with diabetes. tributing to the rising incidence of type 2 diabetes among
Aboriginal people. Thus, a return to a traditional diet is
Travel encouraged, provided the foods selected are safe, acceptable
Many people with diabetes experience difficulty man- and accessible to the individual.A return to traditional activ-
aging their diabetes when travelling. Individuals who use ity levels may also be useful in achieving positive health
insulin and/or insulin secretagogues may have increased outcomes (9698).
hypoglycemia and hyperglycemia while travelling due to Acquisition of an understanding of the Aboriginal
several factors including the following: time changes, lack ethno-specific communication patterns and an under-
of or abundance of food, restaurant eating and lack of standing of the learning styles of Aboriginal people are
physical activity or excess of unplanned physical activity. important in nutritional assessments and in providing
These individuals should be made aware of the possible nutritional advice. Incorporating these into the diabetes
hypoglycemia and hyperglycemia that may result, and education provided may remove barriers to effective meal
strategies to prevent this should be discussed. planning and health care (99,100).
Since meals on trains and planes may not meet
dietary needs, the individual using insulin and/or insulin Recommendations
secretagogues should be prepared to prevent and treat Culturally specific food practices and preferences of
hypoglycemia. Extra carbohydrate foods need to be carried people with diabetes should be considered in meal
with the individual to supplement the diet if meals are planning.
inadequate or delayed. Airlines often provide special meals Returning to a traditional diet (provided the foods are
for people with diabetes; however, in practice these meals safe, acceptable and accessible) and returning to tradi-
tend to be low in carbohydrate. tional activity levels should be considered for Aboriginal
Counselling on insulin and/or insulin secretagogue people in achieving positive health outcomes.
adjustments for travel across time zones should be Diabetes education should include understanding
individualized (91,92). the communication patterns and learning styles of
Aboriginal people to facilitate effective meal planning
Recommendations and health care.
Education should be provided about strategies to
prevent hypoglycemia and hyperglycemia while OTHER CONSIDERATIONS
travelling. Weight management and obesity
The person with diabetes should have carbohydrate Overweight is currently defined as a body mass
foods available to prevent or treat hypoglycemia. index (BMI = wt (kg)/ht (m)2) of 25.029.9 kg/m2,
Counselling on insulin and/or insulin secretagogue with obesity defined as a BMI 30.0 kg/m2 (101). In
adjustments when travelling across times zones addition to BMI, measurement of waist circumference
should be individualized. is recommended as a simple means of assessing obesity
10

independent of height, and may be more meaningful achievable, time-limited target such as 7 kg over
to people with diabetes than their BMI (101). For adults 3 months.
with a BMI of 25.034.9 kg/m2, a waist circumference Weight loss of 510% of initial weight should be
102 cm (40 inches) in men and 88 cm (35 inches) in sufficient to result in significant improvement in
women is a sign of excess abdominal fat, which is associat- glycemic control and other co-morbidities.
ed with an increased risk of metabolic complications (102). The health care team should be consulted, as a down-
The prevalence of obesity has doubled over the last 20 ward adjustment of insulin and/or insulin secretagogue
years in Canada, and there is an alarming increase in the doses may be necessary as a person with diabetes
number of overweight and obese children. In developed loses weight.
countries like Canada, there is a gradual rise in body If weight loss is not possible, prevention of further
weight and increase in percent body fat with age at least weight gain should be attempted.
until 6065 years of age (101). Weight loss is best achieved with a combination of
About 80% of people with type 2 diabetes are increased physical activity and reduced energy intake.
overweight. Indeed, most cases of type 2 diabetes might be Sixty minutes of physical activity daily and a diet
prevented or delayed by early and effective weight containing 30% energy from fat including a variety
management. In addition to increased diabetes and of foods such as whole fruits and vegetables and
cardiovascular risk factors, people with a large waist appropriately refined whole grain products are recom-
circumference frequently experience more breathlessness, mended for long-term weight management.
back pain and difficulties in walking, shopping, climbing Screening for and management of risk factors associat-
stairs, bending over, bathing and dressing (103). Many ed with obesity, such as dyslipidemia, hypertension and
symptoms experienced by overweight people with dia- hyperglycemia are recommended.
betes may be related more to excess body weight than poor
glycemic control.Weight management improves all aspects Hypertension
of diabetes control, including blood glucose, blood lipids Controlling hypertension in people with type 2 diabetes
and hypertension. However, attainment of desirable body reduces the risk of diabetes-related deaths, diabetes com-
weight is not always necessary to achieve good metabolic plications, progression of diabetic retinopathy and
control, which is the primary aim of diabetes therapy. deterioration in visual acuity (107). In those with diabetes,
Weight management is best achieved by strategies that hypertension (i.e. blood pressure 140/90 mm Hg) should
promote gradual rather than quick weight loss.Very-low- be treated to attain target blood pressure < 130/85 mm Hg
calorie diets are known to produce short-term benefits that (71). Non-pharmacological treatment of hypertension in
disappear over the long term (104,105). Weight manage- most people with diabetes is the same as for those without
ment in obesity should focus on adopting a healthy diabetes (108). Often this is part of a general strategy to
lifestyle through food choices and regular physical activity. attain healthy weight through balanced eating and regular
Reducing energy intake by restricting dietary fat is consid- activity (109,110). A sodium restriction of 24 g/d may
ered a better nutritional strategy for achieving weight loss benefit those who are salt-sensitive (111). Avoidance or
in people with diabetes than a general restriction of energy restriction of alcohol intake and smoking cessation may
(106) and may also reduce the risks of heart disease and also be beneficial. Pharmacological therapy is indicated
some forms of cancer. Canadas Physical Activity Guide to when lifestyle interventions are unsuccessful in controlling
Healthy Active Living recommends 60 minutes of physical hypertension (71).
activity every day. For moderate activities such as brisk
walking, the goal is 3060 minutes per day. The physical Recommendations
activity can be spread throughout the day, with several bouts People with diabetes should be encouraged to achieve
of activity lasting 10 minutes each being just as effective as and maintain target blood pressure through balanced
a single bout lasting 2030 minutes. Individuals with a eating, regular activity, weight management and
sedentary lifestyle may not be fit enough to achieve imme- smoking cessation.
diately the recommended amount of physical activity on a Sodium and alcohol restriction should be encouraged
daily basis.Thus, a gradual increase in the intensity, duration and may be beneficial.
and frequency of physical activity should be recommended Antihypertensive medications are recommended if
over a period of weeks or months on an individual basis. lifestyle interventions are unsuccessful in managing
Follow-up visits with the health care team are important in hypertension.
assessing adjustments that may be required as a result of the
individuals weight management routine. Dyslipidemia
People with diabetes have a two- to threefold increase
Recommendations in mortality due to cardiovascular disease (112).Therefore,
Healthy weight gain in childhood and throughout adult these individuals should aim to achieve and maintain target
life should be a goal for people with diabetes. lipid levels, as defined in the Clinical Practice Guidelines
When appropriate, gradual weight loss of 0.251.0 kg (71). Dyslipidemia is often a characteristic of poor glycemic
(0.52.0 lbs) per week should be advised with an control. Consequently, the first approach in managing
 POSITION PAPER 11

dyslipidemia is to improve blood glucose levels through Neuropathy

dietary modifications, regular physical activity and, if Gastroparesis is a form of diabetic neuropathy that can
necessary, adjustments of diabetes medications (71). Better affect the digestion of food and retard glucose absorption.
glycemic control often improves but does not always Gastropathy is a broader term used to describe various dis-
optimize lipid levels. The nutritional approaches used to orders of upper gastrointestinal motility that are prevalent
manage dyslipidemia in individuals with diabetes are essen- in diabetes. Gastropathy can result in postprandial hypo-
tially the same as for those who do not have diabetes. If glycemia that is later followed by higher than normal blood
LDL cholesterol and triglycerides remain suboptimal after glucose rises. Symptoms of gastropathy can include early
attempts to improve glycemic control and modify fat satiety, decreased appetite, bloating, abdominal discomfort,
intake, lipid-lowering agents may be introduced. nausea, vomiting and unexplained hypo/hyperglycemia.
These symptoms may subside with improved blood
Recommendations glucose control. Dietary strategies that may prove useful in
Glycemic control should be improved as a first the treatment of gastropathy include the following:
approach in managing dyslipidemia. chewing food thoroughly; having small, frequent, low-fat
General nutrition management of dyslipidemia in meals; increasing the intake of foods of higher liquid con-
individuals with diabetes should be the same as for those sistency; eating solids as tolerated; and maintaining a
without diabetes. low-fibre diet to discourage the development of bezoars.
If necessary, lipid-lowering agents to control LDL Nutritional supplements, multivitamin/minerals and in
cholesterol and triglycerides should be introduced. some cases enteral or parenteral feedings may be necessary
to meet nutritional requirements. Gastropathy may also be
Nephropathy managed with various pharmacological agents.Gastropathy
Persons with diabetes are several times more prone to in people with diabetes can vary widely in severity and can
kidney disease than the general population. Consequently, severely complicate diabetes management. Each case must
nutritional recommendations in people with diabetes and be approached individually; blood glucose monitoring is
renal disease depend on the degree of nephropathy and recommended to assist in the appropriate adjustment to
concurrent treatments such as dialysis and transplantation. medication if required (117).
Limiting protein intake to no more than requirements
(0.86 g/kg/d for adults) is considered sufficiently restric- Recommendations
tive to manage diabetic nephropathy at all stages of the Dietary strategies to manage gastropathy should be
disease (113). Restricting protein intake to less than individualized and may include the following:
requirements has no additional benefit on the progression chewing food thoroughly; having small, frequent low-
of renal disease and may result in inadequate intake of fat meals; increasing intake of foods of higher liquid
essential amino acids. However, there is some evidence that consistency; eating solids as tolerated; and maintaining
the use of non-meat protein sources may be preferable to a low-fibre diet to discourage the development of
animal protein sources in the management of renal disease. bezoars.
Non-meat protein sources reduce glomerular filtration Nutritional supplements, multivitamin/minerals and
(114) and are associated with lower protein and phosphate in some cases enteral or parenteral feedings may be
intakes (115) and beneficial effects on blood pressure, body necessary to meet nutrition requirements.
weight and blood lipids (116). People with diabetes can be People with gastropathy and diabetes should be
encouraged to include vegetable protein sources in their encouraged to self monitor blood glucose frequently
meal plans, with attention to the use of complementary to aid in adapting diabetes medications to abnormal
protein sources (e.g. combining legumes or peanuts with glucose absorption and to improve overall glycemic
grains) to ensure high protein quality. Further research is control.
needed before more definitive recommendations can be
made. Restriction of sodium, potassium and phosphorus Considerations for insulin and/or insulin
intakes should be considered on an individual basis based secretagogue users
on the results of laboratory tests. Although registered dietitians cannot order diabetes
medications for people with diabetes, they remain inte-
Recommendations gral in the decision of which agent/regimen may be best
Diabetic nephropathy should be managed by limit- suited for the eating habits and lifestyle of people with
ing protein intake to 0.86 g/kg/day in adults. For diabetes. It is essential that registered dietitians work
children, protein intake should be limited to the closely with all other team members to ensure that the
recommended nutrient intake (RNI) for age and lifestyle of the individual with diabetes is not unduly
gender. compromised because of the choice of medicine or
Some animal protein should be substituted with high- regime. Treatment of diabetes with medicine brings to
quality non-meat protein sources. light various considerations that do not exist when just
Sodium, potassium and phosphorus restriction should treating with diet and physical activity alone. Some of
be individualized. these considerations are discussed below.
12

Hypoglycemia and/or insulin secretagogues may necessitate changes to

The greater the effort to attain near-normoglycemia these medications and possibly food intake, as previously
with insulin and/or insulin secretagogues, the greater the discussed in the Weight management and obesity and
risk of hypoglycemia (4,118). Persons taking insulin and/or Exercise sections of this document.
insulin secretagogues should always carry a source of fast-
acting carbohydrate such as glucose tablets or fruit juice. Carbohydrate counting
These individuals should be taught to recognize the early Carbohydrate counting can aid the person with diabetes
symptoms of hypoglycemia and to treat this immediately in achieving better blood glucose control while providing
with at least 1015 g of carbohydrate. For some people, the considerable variety in the diet. Carbohydrate counting
amount may need to be increased and/or repeated. can be used in meal-planning strategies that allow for both
However, it is as important to avoid overtreating low blood consistent and inconsistent carbohydrate intake (i.e. with
glucose as it is to avoid undertreating (119). Continued insulin to carbohydrate ratios) (126). In the Diabetes
treatment with carbohydrate until the symptoms of hypo- Control and Complications Trial, participants with a
glycemia disappear often results in extreme hyperglycemia consistent carbohydrate intake generally found it easier to
prior to the next meal. Ideally, a capillary blood glucose test attain target blood glucose than those who ate carbohy-
should be done before consuming carbohydrate to confirm drate inconsistently (119,125). However, since the focus is
a low blood glucose level exists and 1020 minutes after on carbohydrate, care must be taken to help the persons
eating to confirm treatment was appropriate. Depending with diabetes achieve a nutritionally adequate diet.
on the individual, the reason for the low blood glucose, the
diabetes medications used and the interval to the next New and future diabetes medications
meal, it may be necessary to follow the treatment with a Numerous new medicines for the treatment of diabetes
snack to prevent the hypoglycemia from recurring. have been or soon will be introduced into Canada. In the
Hypoglycemia may occur immediately after or during future, more insulin analogues, both fast- and slow-acting,
meals in individuals using regular insulin or fast-acting will likely be available. As well, new insulin secretagogues
insulin analogues who have started the meal with their are expected to be available in the near future. Registered
blood glucose in the 45 mmol/L range. In this instance, dietitians and other diabetes health care team members
glucose administered against the mucosal lining of the need to educate themselves continually regarding the
mouth may be the most effective method of treatment.To actions of these new medicines and possible effects on
help avoid such an incident, fast-acting analogue insulin lifestyle that these medicines may have. Registered dietitians
users should be reminded to eat immediately or no later unfamiliar with diabetes medications and management
than 15 minutes after injection of insulin (120). People strategies are encouraged to contact diabetes educators
with frequent hypoglycemic episodes of this nature, which who have expertise in this area.
are not corrected with insulin dose adjustment, may
consider taking insulin after the meal. Of interest, those on Recommendations
a fast-acting analogue may experience less hypoglycemia The registered dietitian should work with the
compared to those on regular insulin (121). health care team to ensure that the appropriate
Metformin and alpha-glucosidase inhibitors do not medication/regime is prescribed to accommodate the
usually cause hypoglycemia when used on their own. lifestyle of the individual with diabetes.
However, used in combination with insulin and/or an All insulin and insulin secretagogue users, their families
insulin secretagogues, the risk of hypoglycemia exists. Low and support persons should be instructed on how to
blood glucose in insulin and/or insulin secretagogue users prevent, recognize and treat low blood glucose.
who also take an alpha-glucosidase inhibitor should only Individuals with diabetes should be informed of the
be treated with monosaccharides (such as glucose), likelihood of weight gain with initiation or intensifica-
since alpha-glucosidase inhibitors slow the absorption of tion of insulin therapy. Reduced energy intake and/or
disaccharides (i.e. sucrose) (122,123). increased physical activity may be considered at time of
initiation of the new insulin therapy.
Weight Care should be taken to ensure those instructed to use
Weight often increases in people newly started on carbohydrate counting for blood glucose control are
insulin and those with previous poor control who are also instructed on the basics of healthy eating and
attempting to achieve better control.This is usually a result weight management.
of less caloric loss through glycosuria, a reduced resting All diabetes health care team members should
metabolic rate resulting from better blood sugar control regularly seek to keep informed of diabetes manage-
and, in some cases, rehydration. Consequently, persons with ment changes and advancements.
diabetes newly starting on insulin or more intensive insulin
therapies may wish to consider, with their diabetes health PREVENTION OF TYPE 2 DIABETES
care team, either increasing activity or decreasing food People with established impaired glucose tolerance
intake at initiation of therapy (124,125). Otherwise, weight (IGT) or impaired fasting glucose (IFG) are at increased
loss and/or physical activity in those established on insulin risk of developing type 2 diabetes (127129) and heart
 POSITION PAPER 13

disease (130). Dietary modifications and physical activity CDE, Lise Gagnon DtP, Kerry Grady-Vincent MHSc
have been reported as ways to reduce the development of RD, Lori Hards RD, Frances Hastings RDN, Marjorie
type 2 diabetes (131). For this reason, the same nutrition Hollands MSc RD CDE, Alexandra Jenkins RD CDE,
guidelines that apply to people with type 2 diabetes are David J.A. Jenkins MD PhD DSc, Suzanne Johnson
appropriate for individuals with IGT or IFG. RDN, Louise Leclerc MSc PDt, Lawrence Leiter MD
FRCP(C) FACP, Lise Lvesque RD, Gary Lewis MD
Recommendations FRCP(C), Cathie Martin BSc RD CDE, John H.
Individuals with IGT or IFG should be provided with McNeill PhD, Adi Mehta MD FRCP(C) FACE, Anne
the same nutrition and physical activity guidelines that Murray PDt MAEd CDE, Cline Raymond DtP, Sethu
apply to people with type 2 diabetes. Reddy MD, Claire Robillard RD, Manon Robitaille DtP,
Ann Sclater MD MSc FRCP(C), Jennifer Snyder PDt
SUMMARY MSc, Christiane So DtP, Elise Taillon DtP, Sandi Williams
Nutrition management is a key component for the long- BA MEd RD CDE, Jean-Franois Yale MD, Bernard
term health and quality of life for people with diabetes.The Zinman MD FACP FRCP(C).
general principles for nutrition recommendations are the
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14

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