Optimal nutrient distribution -
study was mostly a collagen hydrolysate i. Finally, the study participants in the Andersen et al. More recently, Schoenfeld and colleagues [ ] published the first longitudinal study to directly compare the effects of ingesting 25 g of whey protein isolate either immediately before or immediately after each workout.
This study is significant as it is the first investigation to attempt to compare pre versus post-workout ingestion of protein. The authors raised the question that the size, composition, and timing of a pre-exercise meal may impact the extent to which adaptations are seen in these studies. However, a key limitation of this investigation is the very limited training volumes these subjects performed.
The total training sessions over the week treatment period was 30 sessions i. One would speculate that the individuals who would most likely benefit from peri-workout nutrition are those who train at much higher volumes. For instance, American collegiate athletes per NCAA regulations NCAA Bylaw 2.
Thus, the average college athlete trains more in two weeks than most subjects train during an entire treatment period in studies in this category.
In one of the only studies to use older participants, Candow and colleagues [ 15 ] assigned 38 men between the ages of 59—76 years to ingest a 0. While protein administration did favorably improve resistance-training adaptations, the timing of protein before or after workouts did not invoke any differential change.
An important point to consider with the results of this study is the sub-optimal dose of protein approximately 26 g of whey protein versus the known anabolic resistance that has been demonstrated in the skeletal muscle of elderly individuals [ ].
In this respect, the anabolic stimulus from a g dose of whey protein may not have sufficiently stimulated muscle protein synthesis or have been of appropriate magnitude to induce differences between conditions.
Clearly, more research is needed to determine if a greater dose of protein delivered before or after a workout may exert an impact on adaptations seen during resistance training in an elderly population. Limited studies are available that have examined the effect of providing protein throughout an acute bout of resistance exercise, particularly studies designed to explicitly determine if protein administration during exercise was more favorable than other times of administration.
However, when examined over the course of 12 weeks, the increases in fiber size seen after ingesting a solution containing 6 g of EAA alone was less than when it was combined with carbohydrate [ 96 ].
The post-exercise time period has been aggressively studied for its ability to heighten various training outcomes. While a large number of acute exercise and nutrient administration studies have provided multiple mechanistic explanations for why post-exercise feeding may be advantageous [ , , , , ], other studies suggest this study model may not be directly reflective of adaptations seen over the course of several weeks or months [ ].
As highlighted throughout the pre-exercise protein timing section, the majority of studies that have examined some aspect of post-exercise protein timing have done so while also administering an identical dose of protein immediately before each workout [ 16 , , , ].
These results, however, are not universal as Hoffman et al. Of note, participants in the Hoffman study were all highly-trained collegiate athletes who reported consuming a hypoenergetic diet. Candow et al. As mentioned previously, it is possible that the dose of protein may not have been an appropriate amount to properly stimulate anabolism.
In this respect, a small number of studies have examined the impact of solely ingesting protein after exercise. As discussed earlier, Tipton and colleagues [ ] used an acute model to determine changes in MPS rates when a g bolus of whey protein was ingested immediately before or immediately after a single bout of lower-body resistance training.
MPS rates were significantly, and similarly, increased under both conditions. Until recently, the only study that examined the effects of post-exercise protein timing in a longitudinal manner was the work of Esmarck et al.
In this study, 13 elderly men average age of 74 years consumed a small combination of carbohydrates 7 g , protein 10 g and fat 3 g either immediately within 30 min or 2 h after each bout of resistance exercise done three times per week for 12 weeks. Changes in strength and muscle size were measured, and it was concluded that ingesting nutrients immediately after each workout led to greater improvements in strength and muscle cross-sectional area than when the same nutrients were ingested 2 h later.
While interesting, the inability of the group that delayed supplementation but still completed the resistance training program to experience any measurable increase in muscle cross-sectional area has led some to question the outcomes resulting from this study [ 5 , ].
Further and as discussed previously with the results of Candow et al. Schoenfeld and colleagues [ ] published results that directly examined the impact of ingesting 25 g of whey protein immediately before or immediately after bouts of resistance-training.
All study participants trained three times each week targeting all major muscle groups over a week period, and the authors concluded no differences in strength and hypertrophy were seen between the two protein ingestion groups.
These findings lend support to the hypothesis that ingestion of whey protein immediately before or immediately after workouts can promote improvements in strength and hypertrophy, but the time upon which nutrients are ingested does not necessarily trump other feeding strategies.
Reviews by Aragon and Schoenfeld [ ] and Schoenfeld et al. The authors suggested that when recommended levels of protein are consumed, the effect of timing appears to be, at best, minimal. Indeed, research shows that muscles remain sensitized to protein ingestion for at least 24 h following a resistance training bout [ ] leading the authors to suggest that the timing, size and composition of any feeding episode before a workout may exert some level of impact on the resulting adaptations.
In addition to these considerations, recent work by MacNaughton and colleagues [ ] reported that the acute ingestion of a g dose versus g of whey protein resulted in significantly greater increases in MPS in young subjects who completed an intense, high volume bout of resistance exercise that targeted all major muscle groups.
Notwithstanding these conclusions, the number of studies that have truly examined a timing question is rather scant. Moreover, recommendations must capture the needs of a wide range of individuals, and to this point, a very small number of studies have examined the impact of nutrient timing using highly trained athletes.
From a practical standpoint, some athletes may struggle, particularly those with high body masses, to consume enough protein to meet their required daily needs. As a starting point, it is important to highlight that most of the available research on this topic has largely used non-athletic, untrained populations except two recent publications using trained men and women [ , ].
Whether or not these findings apply to highly trained, athletic populations remains to be seen. Changes in weight loss and body composition were compared, and slightly greater weight loss occurred when the majority of calories was consumed in the morning. As a caveat to what is seemingly greater weight loss when more calories are shifted to the morning meals, higher amounts of fat-free mass were lost as well, leading to questions surrounding the long-term efficacy of this strategy regarding weight management and metabolic activity.
Notably, this last point speaks to the importance of evenly spreading out calories across the day and avoiding extended periods of time where no food, protein in particular, is consumed.
A large observational study [ ] examined the food intake of free-living individuals males and females ,and a follow-up study from the same study cohort [ ] reported that the timing of food consumption earlier vs. later in the day was correlated to the total daily caloric intake.
Wu and colleagues [ ] reported that meals later in the day lead to increased rates of lipogenesis and adipose tissue accumulation in an animal model and, while limited, human research has also provided support.
Previously it has been shown that people who skip breakfast display a delayed activation of lipolysis along with an increase in adipose tissue production [ , ]. More recently, Jakubowicz and colleagues [ ] had overweight and obese women consume cal each day for a week period.
Approximately 2. While these results provide insight into how calories could be more optimally distributed throughout the day, a key perspective is that these studies were performed in sedentary populations without any form of exercise intervention. Thus, their relevance to athletes or highly active populations might be limited.
Furthermore, the current research approach has failed to explore the influence of more evenly distributed meal patterns throughout the day. Meal frequency is commonly defined as the number of feeding episodes that take place each day. For years, recommendations have indicated that increasing meal frequency may serve as an effective way to influence weight loss, weight maintenance, and body composition.
These assertions were based upon the epidemiological work of Fabry and colleagues [ , ] who reported that mean skinfold thickness was inversely related to the frequency of meals.
One of these studies involved overweight individuals between 60 and 64 years of age while the other investigation involved 80 participants between the ages of 30—50 years of age. An even larger study published by Metzner and colleagues [ ] reported that in a sample of men and women between 35 and 60 years of age, meal frequency and adiposity were inversely related.
While intriguing, the observational nature of these studies does not agree with more controlled experiments. For example, a study by Farshchi et al. The irregular meal pattern was found to result in increased levels of appetite, and hunger leading one to question if the energy provided in each meal was inadequate or if the energy content of each meal could have been better matched to limit these feelings while still promoting weight loss.
Furthermore, Cameron and investigators [ ] published what is one of the first studies to directly compare a greater meal frequency to a lower frequency.
In this study, 16 obese men and women reduced their energy intake by kcals per day and were assigned to one of two isocaloric groups: one group was instructed to consume six meals per day three traditional meals and three snacks , while the other group was instructed to consume three meals per day for an eight-week period.
Changes in body mass, obesity indices, appetite, and ghrelin were measured at the end of the eight-week study, and no significant differences in any of the measured endpoints were found between conditions. These results also align with more recent results by Alencar [ ] who compared the impact of consuming isocaloric diets consisting of two meals per day or six meals per day for 14 days in overweight women on weight loss, body composition, serum hormones ghrelin, insulin , and metabolic glucose markers.
No differences between groups in any of the measured outcomes were observed. A review by Kulovitz et al. Similar conclusions were drawn in a meta-analysis by Schoenfeld and colleagues [ ] that examined the impact of meal frequency on weight loss and body composition.
Although initial results suggested a potential advantage for higher meal frequencies on body composition, sub-analysis indicated that findings were confounded by a single study, casting doubt as to whether the strategy confers any beneficial effects. From this, one might conclude that greater meal frequency may, indeed, favorably influence weight loss and body composition changes if used in combination with an exercise program for a short period of time.
Certainly, more research is needed in this area, particularly studies that manipulate meal frequency in combination with an exercise program in non-athletic as well as athletic populations. Finally, other endpoints related to meal frequency i.
may be of interest to different populations, but they extend beyond the scope of this position stand. An extension of altering the patterns or frequency of when meals are consumed is to examine the pattern upon which protein feedings occur. Moore and colleagues [ ] examined the differences in protein turnover and synthesis rates when participants ingested different patterns, in a randomized order, of an g total dose of protein over a h measurement period following a bout of lower body resistance exercise.
One of the protein feeding patterns required participants to consume two g doses of whey protein isolate approximately 6 h apart.
Another condition required the consumption of four, g doses of whey protein isolate every 3 h. The final condition required the participants to consume eight, g doses of whey protein isolate every 90 min. Rates of muscle protein turnover, synthesis, and breakdown were compared, and the authors concluded that protein turnover and synthesis rates were greatest when intermediate-sized g doses of whey protein isolate were consumed every 3 h.
One of the caveats of this investigation was the very low total dose of protein consumed. Eighty grams of protein over a h period would be grossly inadequate for athletes performing high volumes of training as well as those who are extremely heavy e. A follow-up study one year later from the same research group determined myofibrillar protein synthesis rates after randomizing participants into three different protein ingestion patterns and examined how altering the pattern of protein administration affected protein synthesis rates after a bout of resistance exercise [ ].
Two key outcomes were identified. First, rates of myofibrillar protein synthesis rates increased in all three groups. Second, when four, g doses of whey protein isolate were consumed every 3 h over a h post-exercise period, significantly greater in comparison to the other two patterns of protein ingestion rates of myofibrillar protein synthesis occurred.
In combining the results of both studies, one can conclude that ingestion of intermediate protein doses 20 g consumed every 3 h creates more favorable changes in both whole-body as well as myofibrillar protein synthesis [ , ].
Although both studies employed short-term methodology and other patterns or doses have yet to be examined, the results thus far consistently suggest that the timing or pattern in which high-quality protein is ingested may favorably impact net protein balance as well as rates of myofibrillar protein synthesis.
An important caveat to these findings is that supplementation in most cases was provided in exclusion of other macronutrients over the duration of the study. Consumption of mixed meals delays gastric emptying and thus may result in different metabolic effects.
Moreover, the fact that whey is a fast-absorbing protein source [ ] further confounds the ability to generalize results to traditional mixed-meal diets, as the potential for oxidation is increased with larger dosages, particularly in the absence of other macronutrients.
Whether acute MPS responses translate to longitudinal changes in hypertrophy or fiber composition also remains to be determined [ ]. Protein pacing involves the consumption of 20—40 g servings of high-quality protein, from both whole food and protein supplementation, evenly spaced throughout the day, approximately every 3 h.
The first meal is consumed within 60 min of waking in the morning, and the last meal is eaten within 3 h of going to sleep at night. Arciero and colleagues [ , ] have most recently demonstrated increased muscular strength and power in exercise-trained physically fit men and women using protein pacing compared to ingestion of similar sized meals at similar times but different protein contents, both of which included the same multi-component exercise training during a week intervention.
In support of this theory one can point to the well characterized changes seen in peak MPS rates within 90 min after oral ingestion of protein [ ] and the return of MPS rates to baseline levels in approximately 90 min despite elevations in serum amino acid levels [ ]. Thus if efficacious protein feedings are placed too close together it remains possible that the ability of skeletal muscle anabolism to be fully activated might be limited.
While no clear consensus exists as to the acceptance of this theory, conflicting findings exist between longitudinal studies that did provide protein feedings in close proximity to each other [ 16 , , ], making this an area that requires more investigation.
Finally, while the mechanistic implications of pulsed vs. bolus protein feedings and their effect on MPS rates may help ultimately guide application, the practical importance has yet to be demonstrated.
Eating before sleep has long been controversial [ , , ]. However, methodological considerations in the original studies such as the population used, time of feeding, and size of the pre-sleep meal confounds any conclusions that can be drawn.
Recent work using protein-centric beverages consumed min before sleep and 2 h after the last meal dinner have identified pre-sleep protein consumption as advantageous to MPS, muscle recovery, and overall metabolism in both acute and long-term studies [ , ].
For example, data indicate that 30—40 g of casein protein ingested min prior to sleep [ ] or via nasogastric tubing [ ] increased overnight MPS in both young and old men, respectively. Likewise, in an acute setting, 30 g of whey protein, 30 g of casein protein, and 33 g of carbohydrate consumption min pre-sleep resulted in elevated morning resting metabolic rate in fit young men compared to a non-caloric placebo [ ].
Of particular interest is that Madzima et al. This infers that casein protein consumed pre-sleep maintains overnight lipolysis and fat oxidation. This finding was verifiedwhen Kinsey et al.
It was concluded that pre-sleep casein did not blunt overnight lipolysis or fat oxidation. Similar to Madzima et al. Of note, it appears that previous exercise training completely ameliorates any rise in insulin when eating at night before sleep [ ] and the combination of pre-sleep protein and exercise has been shown to reduce blood pressure and arterial stiffness in young obese women with prehypertension and hypertension [ ].
To date, only two studies involving nighttime protein have been carried out for longer than four weeks. Snijders et al. The group receiving the protein-centric supplement each night before sleep had greater improvements in muscle mass and strength over the weeks.
Of note, this study was non-nitrogen balanced and the protein group received approximately 1. More recently, in a nitrogen-balanced design using young healthy men and women, Antonio et al.
All subjects maintained their usual exercise program. The authors reported no differences in body composition or performance between the morning and evening casein supplementation groups.
A potential explanation for the lack of findings might stem from the already high intake of protein by the study participants before the study commenced. However, it is worth noting that although not statistically significant, the morning group added 0.
Thus, it appears that protein consumption in the evening before sleep represents another opportunity to consume protein and other nutrients. Certainly more research is needed to determine if timing per se, or the mere addition of total daily protein can affect body composition or recovery via nighttime feeding.
Nutrient timing is an area of research that continues to gather interest from researchers, coaches, and consumers. In reviewing the literature, two key considerations should be made. First, all findings surrounding nutrient timing require appropriate context because factors such as age, sex, fitness level, previous fueling status, dietary status, training volume, training intensity, program design, and time before the next training bout or competition can influence the extent to which timing may play a role in the adaptive response to exercise.
Second, nearly all research within this topic requires further investigation. The reader must keep in perspective that in its simplest form nutrient timing is a feeding strategy that in nearly all situations may be helpful towards the promotion of recovery and adaptations towards training.
This context is important because many nutrient timing studies demonstrate favorable changes that do not meet statistical thresholds of significance thereby leaving the reader to interpret the level of practical significance that exists from the findings.
It is noteworthy that differences in real-world athletic performances can be so small that even strategies that offer a modicum of benefit are still worth pursuing. In nearly all such situations, this approach results in an athlete receiving a combination of nutrients at specific times that may be helpful and has not yet shown to be harmful.
This perspective also has the added advantage of offering more flexibility to the fueling considerations a coach or athlete may employ.
Using this approach, when both situations timed or non-timed ingestion of nutrients offer positive outcomes then our perspective is to advise an athlete to follow whatever strategy offers the most convenience or compliance if for no other reason than to deliver vital nutrients in amounts at a time that will support the physiological response to exercise.
Finally, it is advisable to remind the reader that due to the complexity, cost and invasiveness required to answer some of these fundamental questions, research studies often employ small numbers of study participants.
Also, for the most part studies have primarily evaluated men. This latter point is particularly important as researchers have documented that females oxidize more fat when compared to men, and also seem to utilize endogenous fuel sources to different degrees [ 28 , 29 , 30 ].
Furthermore, the size of potential effects tends to be small, and when small potential effects are combined with small numbers of study participants, the ability to determine statistical significance remains low.
Nonetheless, this consideration remains relevant because it underscores the need for more research to better understand the possibility of the group and individual changes that can be expected when the timing of nutrients is manipulated. In many situations, the efficacy of nutrient timing is inherently tied to the concept of optimal fueling.
Thus, the importance of adequate energy, carbohydrate, and protein intake must be emphasized to ensure athletes are properly fueled for optimal performance as well as to maximize potential adaptations to exercise training.
High-intensity exercise particularly in hot and humid conditions demands aggressive carbohydrate and fluid replacement. Consumption of 1. The need for carbohydrate replacement increases in importance as training and competition extend beyond 70 min of activity and the need for carbohydrate during shorter durations is less established.
Adding protein 0. Moreover, the additional protein may minimize muscle damage, promote favorable hormone balance and accelerate recovery from intense exercise.
For athletes completing high volumes i. The use of a 20—g dose of a high-quality protein source that contains approximately 10—12 g of the EAA maximizes MPS rates that remain elevated for three to four hours following exercise. Protein consumption during the peri-workout period is a pragmatic and sensible strategy for athletes, particularly those who perform high volumes of exercise.
Not consuming protein post-workout e. The impact of delivering a dose of protein with or without carbohydrates during the peri-workout period over the course of several weeks may operate as a strategy to heighten adaptations to exercise.
Like carbohydrate, timing related considerations for protein appear to be of lower priority than the ingestion of optimal amounts of daily protein 1. In the face of restricting caloric intake for weight loss, altering meal frequency has shown limited effects on body composition. However, more frequent meals may be more beneficial when accompanied by an exercise program.
The impact of altering meal frequency in combination with an exercise program in non-athlete or athlete populations warrants further investigation. It is established that altering meal frequency outside of an exercise program may help with controlling hunger, appetite and satiety.
Nutrient timing strategies that involve changing the distribution of intermediate-sized protein doses 20—40 g or 0. One must also consider that other factors such as the type of exercise stimulus, training status, and consumption of mixed macronutrient meals versus sole protein feedings can all impact how protein is metabolized across the day.
When consumed within 30 min before sleep, 30—40 g of casein may increase MPS rates and improve strength and muscle hypertrophy. In addition, protein ingestion prior to sleep may increase morning metabolic rate while exerting minimal influence over lipolysis rates. In addition, pre-sleep protein intake can operate as an effective way to meet daily protein needs while also providing a metabolic stimulus for muscle adaptation.
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Yaspelkis BB, Patterson JG, Anderla PA, Ding Z, Ivy JL. Carbohydrate Supplementation Spares Muscle Glycogen During Variable-Intensity Exercise. Jeukendrup AE, Jentjens R, Moseley L.
Nutritional Considerations In Triathlon. Ivy JL, Res PT, Sprague RC, Widzer MO. Effect Of A Carbohydrate-Protein Supplement On Endurance Performance During Exercise Of Varying Intensity. Saunders MJ, Kane MD, Todd MK.
Effects Of A Carbohydrate-Protein Beverage On Cycling Endurance And Muscle Damage. Saunders MJ, Luden ND, Herrick JE. Consumption Of An Oral Carbohydrate-Protein Gel Improves Cycling Endurance And Prevents Postexercise Muscle Damage.
Mclellan TM, Pasiakos SM, Lieberman HR. Effects Of Protein In Combination With Carbohydrate Supplements On Acute Or Repeat Endurance Exercise Performance: A Systematic Review. Rustad PL, Sailer M, Cumming KT, Jeppesen PB, Kolnes KJ, Sollie O, Franch J, Ivy JL, Daniel H, Jensen J. Intake Of Protein Plus Carbohydrate During The First Two Hours After Exhaustive Cycling Improves Performance The Following Day.
Ivy JL, Goforth HW Jr, Damon BM, Mccauley TR, Parsons EC, Price TB. Early Postexercise Muscle Glycogen Recovery Is Enhanced With A Carbohydrate-Protein Supplement. Zawadzki KM, Yaspelkis BB 3rd, Ivy JL. Carbohydrate-Protein Complex Increases The Rate Of Muscle Glycogen Storage After Exercise.
Berardi JM, Noreen EE, Lemon PW. Recovery From A Cycling Time Trial Is Enhanced With Carbohydrate-Protein Supplementation Vs.
Isoenergetic Carbohydrate Supplementation. Berardi JM, Price TB, Noreen EE, Lemon PW. Postexercise Muscle Glycogen Recovery Enhanced With A Carbohydrate-Protein Supplement. Co-Ingestion Of Protein With Carbohydrate During Recovery From Endurance Exercise Stimulates Skeletal Muscle Protein Synthesis In Humans.
Kraemer WJ, Hatfield DL, Spiering BA, Vingren JL, Fragala MS, Ho JY, Volek JS, Anderson JM, Maresh CM. Effects Of A Multi-Nutrient Supplement On Exercise Performance And Hormonal Responses To Resistance Exercise.
Baty JJ, Hwang H, Ding Z, Bernard JR, Wang B, Kwon B, Ivy JL. The Effect Of A Carbohydrate And Protein Supplement On Resistance Exercise Performance, Hormonal Response, And Muscle Damage.
Tipton KD, Rasmussen BB, Miller SL, Wolf SE, Owens-Stovall SK, Petrini BE, Wolfe RR. Timing Of Amino Acid-Carbohydrate Ingestion Alters Anabolic Response Of Muscle To Resistance Exercise.
Fujita S, Dreyer HC, Drummond MJ, Glynn EL, Volpi E, Rasmussen BB. Essential Amino Acid And Carbohydrate Ingestion Before Resistance Exercise Does Not Enhance Postexercise Muscle Protein Synthesis. J Appl Physiol White JP, Wilson JM, Austin KG, Greer BK, St John N, Panton LB.
Effect Of Carbohydrate-Protein Supplement Timing On Acute Exercise-Induced Muscle Damage. Beelen M, Koopman R, Gijsen AP, Vandereyt H, Kies AK, Kuipers H, Saris WH, Van Loon LJ. Protein Coingestion Stimulates Muscle Protein Synthesis During Resistance-Type Exercise. Bird SP, Mabon T, Pryde M, Feebrey S, Cannon J.
Triphasic Multinutrient Supplementation During Acute Resistance Exercise Improves Session Volume Load And Reduces Muscle Damage In Strength-Trained Athletes. Nutr Res. Bird SP, Tarpenning KM, Marino FE. Metab Clin Exp. Hulmi JJ, Laakso M, Mero AA, Hakkinen K, Ahtiainen JP, Peltonen H. The Effects Of Whey Protein With Or Without Carbohydrates On Resistance Training Adaptations.
Buford TW, Kreider RB, Stout JR, Greenwood M, Campbell B, Spano M, Ziegenfuss T, Lopez H, Landis J, Antonio J. International Society Of Sports Nutrition Position Stand: Creatine Supplementation And Exercise. Kreider RB. Effects Of Creatine Supplementation On Performance And Training Adaptations.
Mol Cell Biochem. Kreider RB, Ferreira M, Wilson M, Grindstaff P, Plisk S, Reinardy J, Cantler E, Al A. Effects Of Creatine Supplementation On Body Composition, Strength, And Sprint Performance.
Abdulla H, Smith K, Atherton PJ, Idris I. Role Of Insulin In The Regulation Of Human Skeletal Muscle Protein Synthesis And Breakdown: A Systematic Review And Meta-Analysis. Greenhaff PL, Karagounis LG, Peirce N, Simpson EJ, Hazell M, Layfield R, Wackerhage H, Smith K, Atherton P, Selby A, et al.
Disassociation Between The Effects Of Amino Acids And Insulin On Signaling, Ubiquitin Ligases, And Protein Turnover In Human Muscle. Rennie MJ, Bohe J, Smith K, Wackerhage H, Greenhaff P. Branched-Chain Amino Acids As Fuels And Anabolic Signals In Human Muscle.
J Nutr. Power O, Hallihan A, Jakeman P. Human Insulinotropic Response To Oral Ingestion Of Native And Hydrolysed Whey Protein. Amino Acids. Staples AW, Burd NA, West DW, Currie KD, Atherton PJ, Moore DR, Rennie MJ, Macdonald MJ, Baker SK, Phillips SM.
Carbohydrate Does Not Augment Exercise-Induced Protein Accretion Versus Protein Alone. Rasmussen BB, Tipton KD, Miller SL, Wolf SE, Wolfe RR. An Oral Essential Amino Acid-Carbohydrate Supplement Enhances Muscle Protein Anabolism After Resistance Exercise.
Pasiakos SM, Mcclung HL, Mcclung JP, Margolis LM, Andersen NE, Cloutier GJ, Pikosky MA, Rood JC, Fielding RA, Young AJ. Leucine-Enriched Essential Amino Acid Supplementation During Moderate Steady State Exercise Enhances Postexercise Muscle Protein Synthesis. Tipton KD, Elliott TA, Cree MG, Aarsland AA, Sanford AP, Wolfe RR.
Stimulation Of Net Muscle Protein Synthesis By Whey Protein Ingestion Before And After Exercise. Andersen LL, Tufekovic G, Zebis MK, Crameri RM, Verlaan G, Kjaer M, Suetta C, Magnusson P, Aagaard P. The Effect Of Resistance Training Combined With Timed Ingestion Of Protein On Muscle Fiber Size And Muscle Strength.
Hoffman JR, Ratamess NA, Tranchina CP, Rashti SL, Kang J, Faigenbaum AD. Effect Of Protein-Supplement Timing On Strength, Power, And Body-Composition Changes In Resistance-Trained Men. Delmonico MJ, Kostek MC, Johns J, Hurley BF, Conway JM.
Can Dual Energy X-Ray Absorptiometry Provide A Valid Assessment Of Changes In Thigh Muscle Mass With Strength Training In Older Adults? Eur J Clin Nutr. Schoenfeld BJ, Aragon A, Wilborn C, Urbina S, Hayward SB, Krieger JW.
Pre- Versus Post-Exercise Protein Intake Has Similar Effects On Muscular Adaptations. Peer J. Ayers K, Pazmino-Cevallos M, Dobose C. The Hour Rule: Student-Athletes Time Commitment To Athletics And Academics. Vahperd Journal. Cuthbertson D, Smith K, Babraj J, Leese G, Waddell T, Atherton P, Wackerhage H, Taylor PM, Rennie MJ.
Anabolic Signaling Deficits Underlie Amino Acid Resistance Of Wasting, Aging Muscle. FASEB J. West DW, Burd NA, Coffey VG, Baker SK, Burke LM, Hawley JA, Moore DR, Stellingwerff T, Phillips SM. Rapid Aminoacidemia Enhances Myofibrillar Protein Synthesis And Anabolic Intramuscular Signaling Responses After Resistance Exercise.
Dreyer HC, Drummond MJ, Pennings B, Fujita S, Glynn EL, Chinkes DL, Dhanani S, Volpi E, Rasmussen BB. Leucine-Enriched Essential Amino Acid And Carbohydrate Ingestion Following Resistance Exercise Enhances Mtor Signaling And Protein Synthesis In Human Muscle. Fujita S, Dreyer HC, Drummond MJ, Glynn EL, Cadenas JG, Yoshizawa F, Volpi E, Rasmussen BB.
Nutrient Signalling In The Regulation Of Human Muscle Protein Synthesis. J Physiol. Bohe J, Low JF, Wolfe RR, Rennie MJ. Latency And Duration Of Stimulation Of Human Muscle Protein Synthesis During Continuous Infusion Of Amino Acids.
Burd NA, West DW, Moore DR, Atherton PJ, Staples AW, Prior T, Tang JE, Rennie MJ, Baker SK, Phillips SM. Enhanced Amino Acid Sensitivity Of Myofibrillar Protein Synthesis Persists For Up To 24 H After Resistance Exercise In Young Men.
Mitchell CJ, Churchward-Venne TA, Parise G, Bellamy L, Baker SK, Smith K, Atherton PJ, Phillips SM. Acute Post-Exercise Myofibrillar Protein Synthesis Is Not Correlated With Resistance Training-Induced Muscle Hypertrophy In Young Men.
Willoughby DS, Stout JR, Wilborn CD. Effects Of Resistance Training And Protein Plus Amino Acid Supplementation On Muscle Anabolism, Mass. And Strength Amino Acids. Esmarck B, Andersen JL, Olsen S, Richter EA, Mizuno M, Kjaer M.
Timing Of Postexercise Protein Intake Is Important For Muscle Hypertrophy With Resistance Training In Elderly Humans. Borde R, Hortobagyi T, Granacher U. Dose-Response Relationships Of Resistance Training In Healthy Old Adults: A Systematic Review And Meta-Analysis.
Schoenfeld BJ, Aragon A, Wilborn C, Urbina SL, Hayward SE, Krieger J. Aragon AA, Schoenfeld BJ. Nutrient Timing Revisited: Is There A Post-Exercise Anabolic Window? Schoenfeld BJ, Aragon AA, Krieger JW. The Effect Of Protein Timing On Muscle Strength And Hypertrophy: A Meta-Analysis. Morton RW, Mcglory C, Phillips SM.
Nutritional Interventions To Augment Resistance Training-Induced Skeletal Muscle Hypertrophy. Front Physiol. Macnaughton LS, Wardle SL, Witard OC, Mcglory C, Hamilton DL, Jeromson S, Lawrence CE, Wallis GA, Tipton KD. The Response Of Muscle Protein Synthesis Following Whole-Body Resistance Exercise Is Greater Following 40 G Than 20 G Of Ingested Whey Protein.
Phys Rep. Arciero PJ, Ives SJ, Norton C, Escudero D, Minicucci O, O'brien G, Paul M, Ormsbee MJ, Miller V, Sheridan C, et al. Protein-Pacing And Multi-Component Exercise Training Improves Physical Performance Outcomes In Exercise-Trained Women: The Prise 3 Study.
Ives SJ, Norton C, Miller V, Minicucci O, Robinson J, O'brien G, Escudero D, Paul M, Sheridan C, Curran K, et al. Multi-Modal Exercise Training And Protein-Pacing Enhances Physical Performance Adaptations Independent Of Growth Hormone And Bdnf But May Be Dependent On Igf-1 In Exercise-Trained Men.
Growth Hormon IGF Res. Keim NL, Van Loan MD, Horn WF, Barbieri TF, Mayclin PL. Weight Loss Is Greater With Consumption Of Large Morning Meals And Fat-Free Mass Is Preserved With Large Evening Meals In Women On A Controlled Weight Reduction Regimen.
De Castro JM. The Time Of Day Of Food Intake Influences Overall Intake In Humans. The Time Of Day And The Proportions Of Macronutrients Eaten Are Related To Total Daily Food Intake. Wu T, Sun L, Zhuge F, Guo X, Zhao Z, Tang R, Chen Q, Chen L, Kato H, Fu Z.
Differential Roles Of Breakfast And Supper In Rats Of A Daily Three-Meal Schedule Upon Circadian Regulation And Physiology.
AMDR is the recommended range of intake for a macronutrient. Protein, fat, and carbohydrates each have their own AMDR. AMDRs are drawn from ample scientific evidence showing that they have a protective effect on health for most people, Passerrello explains.
The AMDR for each macronutrient is expressed as a percentage of the total calories you consume in a day. Admittedly, this is where things can get a little confusing. Along with AMDR, Recommended Dietary Allowances are part of a larger group of research-based nutritional values known as Dietary Reference Intakes DRIs.
DRIs are used for a variety of public health purposes—perhaps most notably, informing the nutrition labels you see on foods. All human cells and tissues contain protein. The body relies on this macronutrient for growth, maintenance, and repair. Protein may also support weight loss by lowering levels of the "hunger hormone" ghrelin.
In addition, protein takes longer to digest than carbohydrates, which may help you feel satisfied for longer. For the biggest health benefits, she recommends seeking out complex carbs found in foods such as vegetables, legumes, and whole grains.
Compared with simple-carb sources such as sugary snacks, food containing complex carbs digest more slowly, providing a steadier release of energy. Dietary fat is a nutrient your body needs to absorb key vitamins—including A, D, E, and K—as well as antioxidants. Fat also helps protect organs and keep the body warm.
This macronutrient adds texture and flavor to meals, and stimulates the release of a hormone called cholecystokinin that helps people feel satisfied. Just bear in mind that some fats are healthier than others.
Unsaturated forms—found in fish, olive oil, nuts, and avocado—are your friends. On the other hand, saturated and trans fats—found in red meat, butter, and some fried foods—may negatively affect heart health when eaten in large amounts, so you might want to consider limiting them in your diet.
This may make meal planning easier for certain people. Still, a little know-how about AMDRs for carbohydrates, fat, and protein may be helpful in providing big-picture guidelines to inform your meal planning. AMDRs are just one element of good nutrition.
A healthy diet is also about choosing a variety of wholesome foods that deliver a range of other nutrients, including vitamins and minerals. Sharon Liao is a freelance writer and editor specializing in health, nutrition, and fitness. She lives in Redondo Beach, California.
This article was reviewed for accuracy in July by Angela Goscilo, MS, RD, CDN , manager of nutrition at WeightWatchers®. The WW Science Team is a dedicated group of experts who ensure all our solutions are rooted in the best possible research.
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Journal of Optimal nutrient distribution International Society Optimal nutrient distribution Sports Nutriejt volume OptomalArticle number: 33 Cite Detoxification for reduced cravings article. Metrics details. The International Society of Sports Distributin ISSN provides an objective and critical review regarding Optimal nutrient distribution timing of macronutrients in reference to healthy, exercising adults and in particular highly trained individuals on exercise performance and body composition. The following points summarize the position of the ISSN:. Nutrient timing incorporates the use of methodical planning and eating of whole foods, fortified foods and dietary supplements. The timing of energy intake and the ratio of certain ingested macronutrients may enhance recovery and tissue repair, augment muscle protein synthesis MPSand improve mood states following high-volume or intense exercise.Nutient of the International Society nutient Sports Optimxl volume 14Article number: 20 Cite distribugion article. Metrics distriution. The International Society of Sports Nutrition ISSN provides an objective and critical review related to the intake of distributiin for healthy, dietribution Optimal nutrient distribution.
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Recommendations regarding Distributipn optimal protein Planted Aquarium Fish Categorization per nutreint for athletes to maximize Distrbiution are distributiion and distrjbution dependent nuttient age and recent distribtion exercise stimuli.
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Rapidly digested proteins that contain high proportions of essential amino acids EAAs and adequate Optimal nutrient distribution, are disfribution effective in stimulating MPS. Different Optimmal and quality distributino protein can affect distribhtion acid nufrient following protein supplementation.
Athletes should consider focusing on nutrien food sources dostribution protein that contain pOtimal of the EAAs i. Distribugion athletes should focus on achieving adequate carbohydrate disstribution to promote optimal performance; the addition of protein may help to offset High-intensity cardio workouts damage and promote recovery.
Pre-sleep casein protein intake 30—40 g provides increases in overnight MPS distrribution metabolic rate without influencing lipolysis. Opttimalthe Nhtrient Society nutrjent Sports Nutriet ISSN published its first distrbution stand devoted to jutrient science Optiaml application of dietary protein intake [ distfibution ].
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This updated position stand nutfient new information diatribution addresses butrient most Nufrient dietary dustribution categories that affect Oprimal active Optima, across domains such as exercise performance, Opti,al composition, protein timing, recommended intakes, protein sources and quality, and the preparation methods of various proteins.
Most of Otpimal scientific distributioj investigating the effects of protein intake Muscle building tips exercise performance has focused nurrient supplemental protein intake. Distributiln a broad perspective, the dependent distributioj of these nutrieht can be categorized nutriennt two domains:.
Very nutruent studies have investigated the O;timal of prolonged periods one distribjtion or more of dietary protein manipulation on endurance performance.
The trained cyclists ingested each diet for a Optimal nutrient distribution distrigution in Otpimal randomized, crossover fashion. Before and following the 7-day diet intervention, a self-paced cycling endurance time trial distribuhion conducted as the primary measure of exercise performance.
It nuttrient be noted however that a 7-day treatment period nutriemt exceedingly distribuution. It is unknown what distribuion effect of nutrieny higher protein diet would be over the course of Optomal weeks or months. Although the number of investigations is Optiaml, it appears as dlstribution increasing protein dstribution Optimal nutrient distribution recommended intakes does not enhance endurance performance [ 2dietribution5 Otimal.
In addition to these studies distributuon spanned one to three distrigution, several acute-response single feeding and exercise nuttrient studies exist, Coenzyme Q immune system which protein was added to a ditribution beverage prior nutrinet or during Opgimal exercise.
Similarly, most of these interventions also reported distriution added improvements in endurance performance when protein was Optimall to a pOtimal beverage as nutriet to carbohydrate alone [ 678 nutreint, 9 ]. An important research design note, distrinution, is that those studies ntrient reported improvements in endurance performance Opti,al protein nuyrient added to nutrien carbohydrate distributjon before and during dsitribution all used a distributiin test [ 10Optimal nutrient distribution12 ].
When specifically interested Boost immune health performance outcomes, a time trial is preferred as it diztribution mimics competition and pacing demands.
In conclusion, added protein Optimmal not appear to improve endurance performance Optlmal given for several Optomal, weeks, or Sweet potato and apple bake prior to and during endurance exercise.
Innovative culinary techniques these reasons, Strategies for improved concentration seems prudent to recommend for Optikal athletes to ingest approximately 0. Another important Control hunger hormones naturally relates to Optimal nutrient distribution impact of ingesting protein along with carbohydrate on rates of protein synthesis and balance during dietribution bouts nutrinet endurance exercise.
Distribuhion and colleagues [ 14 ] determined Optimwl adding diwtribution to hutrient consumption throughout a prolonged untrient of endurance exercise promotes a higher whole body net protein balance, but the added protein does not nutrrient any further impact on rates of MPS.
While performance outcomes were not measured, these results shift the focus of nutrienr ingestion during prolonged bouts of endurance exercise to the ingestion of disteibution.
When adequate carbohydrate is delivered, adding protein to carbohydrate does not appear to improve endurance performance over the course of a few days or weeks. Adding protein during or after an intensive bout of endurance exercise may suppress the rise in plasma proteins linked to myofibrillar damage and reduce feelings of muscle soreness.
There are relatively few investigations on the effects of protein supplementation on endurance performance. The extent to which protein supplementation, in conjunction with resistance training, enhances maximal strength is contingent upon many factors, including:. Co-ingestion of additional dietary ingredients that may favorably impact strength e.
creatine, HMB. Taking each of these variables into consideration, the effects of supplemental protein consumption has on maximal strength enhancement are varied, with a majority of the investigations reporting no benefit [ 1516171819202122232425 ] and a few reporting improvements in maximal strength [ 26272829 ].
With limited exceptions [ 16182327 ], most of the studies utilized young, healthy, untrained males as participants. In one investigation examining college football athletes supplementing with a proprietary milk protein supplement two servings of 42 g per day for 12 weeks, a These differences were statistically significant.
When females were the only sex investigated, the outcomes consistently indicated that supplemental protein does not appear to enhance maximal strength at magnitudes that reach statistical significance. Hida et al. An important note for this study is that 15 g of egg protein is considered by many to be a sub-optimal dose [ 31 ].
However, others have advocated that the total daily intake of protein might be as important or more important [ 32 ]. In another study, Josse et al. In summary, while research investigating the addition of supplemental protein to a diet with adequate energy and nutrient intakes is inconclusive in regards to stimulating strength gains in conjunction with a resistance-training program to a statistically significant degree, greater protein intakes that are achieved from both dietary and supplemental sources do appear to have some advantage.
Hoffman and colleagues [ 29 ] reported that in athletes consuming daily protein intakes above 2. Cermak and colleagues [ 35 ] pooled the outcomes from 22 separate clinical trials to yield subjects in their statistical analysis and found that protein supplementation with resistance training resulted in a A similar conclusion was also drawn by Pasiakos et al.
Results from many single investigations indicate that in both men and women protein supplementation exerts a small to modest impact on strength development. Pooled results of multiple studies using meta-analytic and other systematic approaches consistently indicate that protein supplementation 15 to 25 g over 4 to 21 weeks exerts a positive impact on performance.
Andersen et al. When the blend of milk proteins was provided, significantly greater increases in fat-free mass, muscle cross-sectional area in both the Type I and Type II muscle fibers occurred when compared to changes seen with carbohydrate consumption.
Collectively, a meta-analysis by Cermak and colleagues [ 35 ] reported a mean increase in fat-free mass of 0. Other reviews by Tipton, Phillips and Pasiakos, respectively, [ 363839 ] provide further support that protein supplementation 15—25 g over 4—14 weeks augments lean mass accretion when combined with completion of a resistance training program.
Beyond accretion of fat-free mass, increasing daily protein intake through a combination of food and supplementation to levels above the recommended daily allowance RDA RDA 0. The majority of this work has been conducted using overweight and obese individuals who were prescribed an energy-restricted diet that delivered a greater ratio of protein relative to carbohydrate.
Greater amounts of fat were lost when higher amounts of protein were ingested, but even greater amounts of fat loss occurred when the exercise program was added to the high-protein diet group, resulting in significant decreases in body fat. Each person was randomly assigned to consume a diet that contained either 1× 0.
Participants were measured for changes in body weight and body composition. While the greatest body weight loss occurred in the 1× RDA group, this group also lost the highest percentage of fat-free mass and lowest percentage of fat mass.
Collectively, these results indicate that increasing dietary protein can promote favorable adaptations in body composition through the promotion of fat-free mass accretion when combined with a hyperenergetic diet and a heavy resistance training program and can also promote the loss of fat mass when higher intakes of daily protein × the RDA are combined with an exercise program and a hypoenergetic diet.
When combined with a hyperenergetic diet and a heavy resistance-training program, protein supplementation may promote increases in skeletal muscle cross-sectional area and lean body mass.
When combined with a resistance-training program and a hypoenergetic diet, an elevated daily intake of protein 2 — 3× the RDA can promote greater losses of fat mass and greater overall improvements in body composition.
In the absence of feeding, muscle protein balance remains negative in response to an acute bout of resistance exercise [ 48 ]. Tipton et al. Later, Burd et al. Subsequently, these conclusions were supported by Borsheim [ 52 ] and Volpi [ 53 ]. The study by Borsheim also documented a dose-response outcome characterized by a near doubling of net protein balance in response to a three to six gram dose of the EAAs [ 52 ].
Building on this work, Tipton et al. These findings formed the theoretical concept of protein timing for resistance exercise that has since been transferred to not only other short-duration, high-intensity activities [ 56 ] but also endurance-based sports [ 57 ] and subsequent performance outcomes [ 58 ].
The strategic consumption of nutrition, namely protein or various forms of amino acids, in the hours immediately before and during exercise i.
While earlier investigations reported positive effects from consumption of amino acids [ 374661 ], it is now clear that intact protein supplements such as egg, whey, casein, beef, soy and even whole milk can evoke an anabolic response that can be similar or greater in magnitude to free form amino acids, assuming ingestion of equal EAA amounts [ 626364 ].
For instance, whey protein ingested close to resistance exercise, promotes a higher activation phosphorylation of mTOR a key signaling protein found in myocytes that is linked to the synthesis of muscle proteins and its downstream mRNA translational signaling proteins i.
Moreover, it was found that the increased mTOR signaling corresponded with significantly greater muscle hypertrophy after 10 weeks of training [ 65 ]. However, the hypertrophic differences between protein consumption and a non-caloric placebo appeared to plateau by week 21, despite a persistently greater activation of this molecular signaling pathway from supplementation.
Results from other research groups [ 56575866 ] show that timing of protein near ± 2 h aerobic and anaerobic exercise training appears to provide a greater activation of the molecular signalling pathways that regulate myofibrillar and mitochondrial protein synthesis as well as glycogen synthesis.
It is widely reported that protein consumption directly after resistance exercise is an effective way to acutely promote a positive muscle protein balance [ 315567 ], which if repeated over time should translate into a net gain or hypertrophy of muscle [ 68 ]. Pennings and colleagues [ 69 ] reported an increase in both the delivery and incorporation of dietary proteins into the skeletal muscle of young and older adults when protein was ingested shortly after completion of exercise.
These findings and others add to the theoretical basis for consumption of post-protein sooner rather than later after exercise, since post workout MPS rates peak within three hours and remain elevated for an additional 24—72 h [ 5070 ]. This extended time frame also provides a rationale for both immediate and sustained i.
These temporal considerations would also capture the peak elevation in signalling proteins shown to be pivotal for increasing the initiation of translation of muscle proteins, which for the most part appears to peak between 30 and 60 min after exercise [ 71 ].
However, these differences may be related to the type of protein used between the studies. The studies showing positive effects of protein timing used milk proteins, whereas the latter study used a collagen based protein supplement.
While a great deal of work has focused on post-exercise protein ingestion, other studies have suggested that pre-exercise and even intra-exercise ingestion may also support favorable changes in MPS and muscle protein breakdown [ 145475767778 ]. Initially, Tipton and colleagues [ 54 ] directly compared immediate pre-exercise and immediate post-exercise ingestion of a mixture of carbohydrate 35 g and EAAs 6 g combination on changes in MPS.
They reported that pre-exercise ingestion promoted higher rates of MPS while also demonstrating that nutrient ingestion prior to exercise increased nutrient delivery to a much greater extent than other immediate or one hour post-exercise time points.
These results were later challenged by Fujita in who employed an identical study design with a different tracer incorporation approach and concluded there was no difference between pre- or post-exercise ingestion [ 75 ].
Subsequent work by Tipton [ 79 ] also found that similar elevated rates of MPS were achieved when ingesting 20 g of a whey protein isolate immediately before or immediately after resistance exercise. At this point, whether any particular time of protein ingestion confers any unique advantage over other time points throughout a h day to improve strength and hypertrophy has yet to be adequately investigated.
To date, although a substantial amount of literature discusses this concept [ 6080 ], a limited number of training studies have assessed whether immediate pre- and post-exercise protein consumption provides unique advantages compared to other time points [ 727381 ].
Each study differed in population, training program, environment and nutrition utilized, with each reporting a different result. What is becoming clear is that the subject population, nutrition habits, dosing protocols on both training and non-training days, energy and macronutrient intake, as well as the exercise bout or training program itself should be carefully considered alongside the results.
: Optimal nutrient distribution| Diabetes Canada | Clinical Practice Guidelines | The EER is an estimate of how many calories a person needs to consume, on average, each day to stay healthy, based on their age, sex, height, weight, and physical activity level. For children, the EER includes the energy needed for normal growth. For pregnant or lactating women, it includes energy needed for development of the fetus and other pregnancy requirements or for milk production. Different EER values were also developed for different physical activity levels, because greater physical activity requires more energy. Acceptable Macronutrient Distribution Ranges AMDRs : Ranges of macronutrient intakes that are associated with reduced risk of chronic disease, while providing recommended intakes of other essential nutrients. The AMDR is the calculated range of how much energy from carbohydrate, fat, and protein is recommended for a healthy diet. People who do not meet the AMDR may have increased risk of developing health complications—although these are also ballpark recommendations, not absolute requirements for health. Keep in mind that the percentage of daily caloric intake from the three energy-yielding macronutrients will add up to percent, so the proportion of each influences the other two. The AMDR recommendations are based on balancing carbohydrate, fat, and protein to allow for adequate amounts of all three, and they are wide enough ranges that many different types of diets can fit within them. There are four different types of DRI values used to describe recommendations for intake of individual nutrients:. DRI values are summarized in tables to make it easy to find a specific value for a person based on their life stage and sex. For example, part of a table of EAR values for macronutrients and vitamins is shown below. Estimated Average Requirement EAR : The average daily nutrient intake level estimated to meet the requirement of half the healthy individuals in a particular life stage and gender group. The Estimated Average Requirement EAR is the amount of a nutrient that meets the requirements of 50 percent of people within a group of the same life stage and sex. The requirements of half of the group will fall below the EAR, and the requirements of the other half will be above it. To develop the EAR, a committee of scientists evaluates the research on that nutrient and chooses a specific bodily function as a criterion on which to base it. For example, the EAR for calcium is set using a criterion of maximizing bone health, because this is quantitatively one of the most important functions of calcium, and the effects of different levels of calcium intake on bone health can be measured. Thus, the EAR for calcium is set at a point that will meet the needs, with respect to bone health, of half of the population. Recommended Daily Allowance RDA : The average daily dietary nutrient intake level sufficient to meet the nutrient requirement of nearly all 97 to 98 percent healthy individuals in a particular life stage and gender group. Once the EAR of a nutrient has been established, the RDA value can be mathematically determined. While the EAR is set at a point that meets the needs of half the population, RDA values are set to meet the needs of the vast majority 97 to 98 percent of the target healthy population. You can see this in the graph above. The RDA is a better recommendation for the population, because we can assume that if a person is consuming the RDA of a given nutrient, they are most likely meeting their nutritional needs for that nutrient. This also explains why the RDA is not the same thing as an individual nutritional requirement. The RDA is meant as a recommendation , and meeting the RDA means it is very likely that you are meeting your actual requirement for that nutrient. In practice, both types of recommendations serve as a daily target for intake. However, the EER is set to meet the average caloric needs of a person, while the RDA is set to meet the needs of the vast majority of the population. Imagine if the EER was set to ensure that it met the caloric needs of the vast majority of a population. It would end up being a dramatic overestimate of caloric needs for most people. If everyone actually followed this recommendation, the majority of them would consume far more calories than they actually needed, resulting in weight gain. For nutrients, we have more flexibility in our intake, because we have ways of storing or metabolizing and excreting excess nutrients, so consuming somewhat more than our body needs is just fine. Adequate Intake AI : The recommended average daily intake level based on observed or experimentally determined approximations or estimates of nutrient intake by a group or groups of apparently healthy people that are assumed to be adequate—used when an RDA cannot be determined. When there is insufficient scientific evidence to set an EAR and RDA for the entire population, then the National Academies committee can decide to set an Adequate Intake AI level instead. Whereas the replacement of fat with refined high-GI CHO results in worsening of metabolic parameters in people with type 2 diabetes , the replacement of saturated fatty acids with low-GI CHO or whole grain sources is associated with decreased incident CHD in people with and without diabetes , When protein is used to replace CHO, as in a high-protein diet, benefit has only been demonstrated when high-GI CHO are replaced. These differences were seen despite similar weight loss with normal renal function being maintained Rather, it was adherence to any 1 diet and the degree of energy restriction, not the variation in diet macronutrient composition, that was associated with the long-term improvement in glycemic control and cardiometabolic risk factors Adjustments in medication type and dosage may be required when embarking on a different macronutrient distribution or energy reduction to avoid hypoglycemia. Intensive lifestyle intervention ILI programs in diabetes usually consist of behavioural interventions combining dietary modification and increased physical activity. An interprofessional team, including registered dietitians, nurses and kinesiologists, usually leads the ILl programs, with the intensity of follow up varying from weekly to every 3 months with gradually decreasing contact as programs progress. Large, randomized clinical trials have shown benefit of ILl programs using different lifestyle approaches in diabetes. Twenty-year follow up of the China Da Qing Diabetes Prevention Outcome Study showed that 6 years of an ILl program targeting an increase in vegetable intake, decrease in alcohol and simple sugar intake, weight loss through energy restriction in participants with overweight or obesity, and an increase in leisure time physical activity e. However, it should be noted that analysis after 8 years showed that initial weight loss was attributable to reduction in both fat and lean mass, whereas weight regain was attributable only to fat mass, with continued decline in lean mass Improvements in glycemic control and CV risk factors BP, TG and HDL-C were greatest at 1 year and diminished over time with the most sustainable reductions being in A1C, fitness and systolic BP In , the Look AHEAD trial was stopped early as it was determined that 11 years of an ILl did not decrease the occurrence of CV events compared to the control group and further intervention was unlikely to change this result. It was noted, however, that both groups had a lower number of CV events compared to previous studies of people with diabetes. Other studies of ILI have shown similar results , Although the available trials suggest an overall short-term benefit of different ILl programs in people with diabetes, the feasibility of implementing an ILl program will depend on the availability of resources and access to an interprofessional team. Effects attenuate within 8 years and do not appear to provide lasting CV protection. A variety of dietary patterns have been studied for people with prediabetes and diabetes. An individual's values, preferences and treatment goals will influence the decision to use these dietary patterns. A Mediterranean diet primarily refers to a plant-based diet first described in the s General features include high consumption of fruits, vegetables, legumes, nuts, seeds, cereals and whole grains; moderate-to-high consumption of olive oil as the principal source of fat ; low-to-moderate consumption of dairy products, fish and poultry; low consumption of red meat; and low-to-moderate consumption of wine, mainly during meals , Systematic reviews and meta-analyses of randomized controlled feeding trials have shown that a Mediterranean-style dietary pattern improves glycemic control 50, , and improves systolic BP, TC, HDL-C, TC:HDL-C ratio and TG in type 2 diabetes , A low-CHO Mediterranean-style diet reduced A1C, delayed the need for antihyperglycemic drug therapy and increased rates of diabetes remission compared with a low-fat diet in overweight individuals with newly diagnosed type 2 diabetes at 8 years Compared with a diet based on the American Diabetes Association recommendations, both traditional and low-CHO Mediterranean-style diets were shown to decrease A1C and TG, whereas only the low-CHO Mediterranean-style diet improved LDL-C and HDL-C at 1 year in persons with overweight and type 2 diabetes Both the extra-virgin olive oil and mixed nuts arms of the PREDIMED trial also reduced risk of incident retinopathy. No effect on nephropathy was detected Vegetarian dietary patterns include lacto-ovovegetarian, lactovegetarian, ovovegetarian and vegan dietary patterns. A low-fat, ad libitum vegan diet has been shown to be just as beneficial as conventional American Diabetes Association dietary guidelines in promoting weight loss and improving fasting BG and lipids over 74 weeks in adults with type 2 diabetes and, when taking medication changes into account, the vegan diet improved glycemia and plasma lipids more than the conventional diet On both diets, weekly or biweekly nutrition and cooking instruction was provided by a dietitian or cooking instructor Similarly, a calorie-restricted vegetarian diet was shown to improve BMI and LDL-C more than a conventional diet in people with type 2 diabetes Subsequent systematic reviews and meta-analyses of the available randomized controlled trials have shown that vegetarian and vegan dietary patterns resulted in clinically meaningful improvements in A1C and FBG in people with type 1 and type 2 diabetes over 4 to 74 weeks , , as well as body weight and blood lipids in people with and without diabetes over 3 to 74 weeks. A systematic review and meta-analysis of prospective cohort and cross-sectional observational studies showed a protective association between vegetarian dietary patterns and incident fatal and nonfatal CHD Dietary approaches to reducing BP have focused on sodium reduction and the Dietary Approaches to Stop Hypertension DASH dietary pattern. The DASH dietary pattern does not target sodium reduction but rather emphasizes vegetables, fruits and low-fat dairy products, and includes whole grains, poultry, fish and nuts. It contains smaller amounts of red and processed meat, sweets, sugar-containing beverages, total and saturated fat, and cholesterol, and larger amounts of potassium, calcium, magnesium, dietary fibre and protein than typical Western diets , The DASH dietary pattern has been shown to lower systolic and diastolic BP compared with a typical American diet matched for sodium intake in people with and without hypertension, inclusive of people with well-controlled diabetes , In addition to BP-lowering benefit, a systematic review and meta-analysis of randomized controlled trials showed that a DASH dietary pattern lowered lipids, including LDL-C in people with and without hypertension, some of whom had metabolic syndrome or diabetes A systematic review and meta-analysis of prospective cohort studies that included people with diabetes showed that adherence to a DASH dietary pattern was associated with a reduction in incident CVD These small effects combine to provide a meaningful overall reduction in LDL-C lowering. Although the Portfolio dietary pattern has not been formally tested in people with diabetes, each component has been shown individually to lower LDL-C in systematic reviews and meta-analyses of randomized controlled trials inclusive of people with diabetes 57,59—61,— The results of the Combined Portfolio Diet and Exercise Study PortfolioEx trial , a 3-year multicentre randomized controlled trial of the effect of the Portfolio Diet plus exercise on atherosclerosis, assessed by magnetic resonance imaging MRI in high CV risk people ClinicalTrials. gov Identifier, NCT , will provide important new data in people with diabetes, as approximately one-half of the participants will have type 2 diabetes. The Nordic Diet was developed as a Nordic translation of the Mediterranean, Portfolio, DASH and NCEP dietary patterns, using foods typically consumed as part of a traditional Nordic diet in the context of Nordic Nutrition Recommendations The Nordic Diet has not been studied in people with diabetes; however, 3 high-quality randomized controlled trials have studied the effect of a Nordic Diet on glycemic control and other relevant cardiometabolic outcomes in people with central obesity or metabolic syndrome. These have shown improvements in body weight, insulin resistance, and lipids, including the therapeutically relevant LDL-C and non-HDL-C — Numerous popular weight-loss diets providing a range of macronutrient profiles are available to people with diabetes. Furthermore, the Mediterranean-style diet had a more favourable effect on FPG at 2 years in the subgroup of participants with type 2 diabetes Dietary pulses, the dried seeds of nonoil seed legumes, include beans, peas, chickpeas, and lentils. This taxonomy does not include the oil-seed legumes soy, peanuts or fresh legumes peas, beans. A systematic review and meta-analysis of prospective cohort studies, inclusive of people with diabetes, showed that the intake of 4 weekly g servings of legumes is associated with decreased incident total CHD Eating Well with Canada's Food Guide recommends up to 7 to 10 servings of fruit and vegetables per day Individual randomized controlled trials have shown that supplementation with fresh or freeze dried fruits improves A1C over 6 to 8 weeks in individuals with type 2 diabetes , A novel and simple technique of encouraging intake of vegetables first and other CHOs last at each meal was successful in achieving better glycemic control A1C than an exchange-based meal plan after 24 months of follow up in people with type 2 diabetes A systematic review and meta-analysis of randomized controlled trials also showed that fruit and vegetables provided as either foods or supplements improved diastolic BP over 6 weeks to 6 months in individuals with the metabolic syndrome, some of whom had prediabetes In people with type 1 and type 2 diabetes, an intervention to increase the intake of fruit, vegetables and dairy that only succeeded in increasing the intake of fruits and vegetables, led to a similar improvement in diastolic blood pressure and to a clinically meaningful regression in carotid intima medial thickness over 1 year Although there is a need to understand better the advantages of different fruit and vegetables in people with diabetes, higher intake of total fruit and vegetables remains an important part of all healthy dietary patterns. Nuts include both peanuts a legume and tree nuts, such as almonds, walnuts, pistachios, pecans, Brazil nuts, cashews, hazelnuts, macadamia nuts and pine nuts. An individual patient-level meta-analysis of 25 nut intervention trials of the effect of nuts on lipid outcomes in people with normolipidemia or hypercholesterolemia including 1 trial in people with type 2 diabetes also showed a dose-dependent reduction in blood lipids, including the established therapeutic target LDL-C A systematic review and meta-analysis of prospective cohort studies in people with and without diabetes also showed that the intake of 4 weekly Despite concerns that the high energy density of nuts may contribute to weight gain, systematic reviews of randomized controlled trials have failed to show an adverse effect of nuts on body weight and measures of adiposity when nuts are consumed as part of balanced, healthy dietary patterns , Health Canada defines whole grains as those that contain all 3 parts of the grain kernel bran, endosperm, germ in the same relative proportions as they exist in the intact kernel. Health Canada recommends that at least half of all daily grain servings are consumed from whole grains Sources of whole grains include both the cereal grains e. wheat, rice, oats, barley, corn, wild rice, and rye and pseudocereal grains e. quinoa, amaranth and buckwheat but not oil seeds e. soy, flax, sesame seeds, poppy seeds. Systematic reviews and meta-analyses of randomized controlled trials have shown that whole grain interventions, specifically with whole grain sources containing the viscous soluble fibre beta-glucan, such as oats and barley, improve lipids, including TG and LDL-C, in people with and without diabetes over 2 to 16 weeks of follow up Whole grains have also been shown to improve glycemic control. Whole grains from barley have shown improvements in fasting glucose in people with and without diabetes 57 and whole grains from oats have shown improvements in A1C and FPG in the subgroup with type 2 diabetes In contrast, these advantages have not been seen for whole grain sources from whole wheat or wheat bran in people with type 2 diabetes 56,66, Systematic reviews and meta-analyses of prospective cohort studies have shown a protective association of total whole grains where wheat is the dominant source and total cereal fibre as a proxy of whole grains with incident CHD in people with and without diabetes 69, Although higher intake of all whole grains remains advisable especially from oats and barley , more research is needed to understand the role of different sources of whole grains in people with diabetes. Dairy products broadly include low- and full-fat milk, cheese, yogurt, other fermented products and ice cream. Evidence for the benefit of specific dairy products as singular interventions in the management of diabetes is inconclusive. Systematic reviews and meta-analyses of randomized controlled trials of the effect of diets rich in either low- or full-fat dairy products have not shown any clear advantages for body weight, body fat, waist circumference, FPG or BP across individuals with different metabolic phenotypes otherwise healthy, with overweight or obesity, or metabolic syndrome , The comparator, however, may be an important consideration. Individual randomized controlled trials, which have assessed the effect of dairy products in isocaloric substitution with SSBs and foods, have shown advantages for visceral adipose tissue, systolic blood pressure and triglycerides in individuals with overweight or obesity over 6 months and markers of insulin resistance in people with prediabetes over 6 weeks Other evidence from observational studies is suggestive of a weight loss and CV benefit. Large pooled analyses of the Harvard cohorts have shown that higher intakes of yogurt are associated with decreased body weight over 12 to 20 years of follow up in people with and without diabetes Systematic reviews and meta-analyses of prospective cohort studies inclusive of people with diabetes have also shown a protective association of cheese with incident CHD; low-fat dairy products with incident CHD; and total, low-fat, and full-fat dairy products, and total milk with incident stroke over 5 to 26 years of follow up , For persons on insulin, consistency in CHO intake and spacing and regularity in meal consumption may help control BG levels — Inclusion of snacks as part of a person's meal plan should be individualized based on meal spacing, metabolic control, treatment regimen and risk of hypoglycemia, and should be balanced against the potential risk of weight gain , The nutritional recommendations that reduce CV risk apply to both type 1 and type 2 diabetes. Studies have shown that people with type 1 diabetes tend to consume diets that are low in fibre, and high in protein and saturated fat In addition, it was shown in the Diabetes Control and Complications Trial DCCT , intensively treated individuals with type 1 diabetes showed worse diabetes control with diets high in total and saturated fat and low in CHO Meals high in fat and protein may require additional insulin and, for those using CSII, the delivery of insulin may be best given over several hours Algorithms for improved bolusing are under investigation. Heavy CHO loads greater than 60 g have been shown to result in greater glucose area under the curve and some risk of late postprandial hypoglycemia People with type 1 diabetes or type 2 diabetes requiring insulin, using a basal-bolus regimen, should adjust their insulin based on the CHO content of their meals, and inject their insulin within 15 minutes of eating with rapid-acting insulin analogues and just prior to and if required up to 20 minutes after eating with faster-acting insulin aspart for optimal match between rapid insulin and glycemic meal rise see Glycemic Management of Type 1 Diabetes in Adults chapter, p. Intensive insulin therapy regimens that include multiple injections of rapid-acting insulin matched to CHO allow for flexibility in meal size and frequency , Improvements in A1C, BG and quality of life, as well as less requirement for insulin, can be achieved when individuals with type 1 diabetes or type 2 diabetes receive education on matching insulin to CHO content e. CHO counting , In doing so, dietary fibre and sugar alcohol should be subtracted from total CHO. They also improved individual quality of life and treatment satisfaction Sugar substitutes, which include high-intensity sweeteners and sugar alcohols, are regulated as food additives in Canada. Health Canada has set acceptable daily intake ADI values, which are expressed on a body weight basis and are considered safe daily intake levels over a lifetime Table 2. These levels are considered high and are rarely achieved. Most have been shown to be safe when used by people with diabetes — ; however, there are limited data on the newer sweeteners, such as neotame and thaumatin in people with diabetes. Although systematic reviews and meta-analyses of prospective cohort studies inclusive of people with diabetes have shown an adverse association of non-nutritive sweetened beverages with weight gain, CVD and stroke, it is well recognized that these data are at high risk of reverse causality , The evidence from systematic reviews and meta-analyses of randomized controlled trials, which give a better protection against bias, have shown a weight loss benefit when non-nutritive sweeteners are used to displace excess calories from added sugars especially from SSBs in overweight children and adults without diabetes , a benefit that has been shown to be similar to that seen with other interventions intended to displace excess calories from added sugars, such as water Sugar alcohols approved for use in Canada include: erythritol, isomalt, lactitol, maltitol, mannitol, sorbitol, xylitol. There is no ADI for sugar alcohols except for erythritol as their use is considered self-limiting due to the potential for adverse gastrointestinal symptoms. They vary in the degree to which they are absorbed, and their conversion rate to glucose is slow, variable and usually minimal, and may have no significant effect on BG. Thus, matching rapid-acting insulin to the intake of sugar alcohols is not recommended Weight loss programs for people with diabetes may use partial meal replacement plans. Commercially available, portion-controlled, vitamin- and mineral-fortified meal replacement products usually replace 1 or 2 meals per day in these plans. Randomized controlled feeding trials have shown partial meal replacement plans result in comparable or increased , weight loss compared with conventional reduced-calorie diets for up to 1 year with maintenance up to 86 weeks in people with type 2 diabetes and overweight. This weight loss results in greater improvements in glycemic control over 3 months to 34 weeks , and reductions in the need for antihyperglycemic medications up to 1 year without an increase in hypoglycemic or other adverse events — Meal replacements with differing macronutrient compositions designed for people with diabetes have shown no clear advantage, although studies are lacking , The same precautions regarding alcohol consumption in the general population apply to people with diabetes For people with type 1 diabetes, moderate consumption of alcohol with, or 2 or 3 hours after, an evening meal may result in delayed hypoglycemia the next morning after breakfast or as late as 24 hours after alcohol consumption , and may impede cognitive performance during mild hypoglycemia The same concern may apply to sulphonylurea- and insulin-treated individuals with type 2 diabetes Health-care professionals should discuss alcohol use with people with diabetes to inform them of the potential weight gain and risks of hypoglycemia People with diabetes should be encouraged to meet their nutritional needs by consuming a well-balanced diet by following Eating Well with Canada's Food Guide Routine vitamin and mineral supplementation is generally not recommended. Supplementation with folic acid 0. The need for further vitamin and mineral supplements should be assessed on an individual basis. As vitamin and mineral supplements are regulated as natural health products NHP in Canada, the evidence for their therapeutic role in diabetes has been reviewed in the Complementary and Alternative Medicine for Diabetes chapter, p. Within the lay literature, intermittent energy restriction strategies for weight loss have become more prevalent. To date, there is limited evidence for these approaches with people with type 2 diabetes. Traditionally, Muslims with type 1 and insulin-requiring type 2 diabetes have been exempted from participation in Ramadan fasting, due to concerns of hypo- and hyperglycemia. Similarly, people on non-insulin antihyperglycemic agents associated with hypoglycemia are also considered high risk for fasting. People with diabetes who wish to participate in Ramadan fasting are encouraged to consult with their diabetes health-care team 1 to 2 months prior to the start of Ramadan. While evidence for the impact of Ramadan fasting in individuals with type 1 diabetes is limited, the literature suggests that in people with well-controlled type 1 diabetes, complications from fasting are rare. A reduction in the total daily dose of insulin can reduce the incidence of hypoglycemia. CSII therapy or the use of multiple daily injections with rapid-acting insulin taken with meals and basal insulin, combined with frequent self-monitoring of blood glucose SMBG can help reduce the risk of hypo- and hyperglycemia. Individuals with a history of severe hypoglycemia or hypoglycemia unawareness should be discouraged from participating in Ramadan fasting , pdf While there is no universally agreed upon definition of food skills, it is generally thought that they are interdependent technical, mechanical, conceptual and perceptual skills that are necessary to safely select and plan, prepare, and store nutritious and culturally-acceptable meals and snacks — Several studies suggest that food preparation and cooking skills are declining globally ,, Over the past several decades, in Canada, there has been an increase in processed, pre-prepared and convenience foods being purchased and assembled rather than meals being prepared using whole, basic ingredients To our knowledge, there are no studies that have investigated food skills in people with diabetes. Nevertheless, targeted interventions to improve the food skills of people living with diabetes are prudent given that food is central to managing glycemic control. People with type 1 diabetes may be taught how to match insulin to carbohydrate quantity and quality [Grade C, Level 2 ] or they may maintain consistency in carbohydrate quantity and quality [Grade D, Consensus]. From: Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med 6 6 : e pmed For more information, visit www. Chan reports grants from Danone Institute, Canadian Foundation for Dietetic Research, Alberta Livestock and Meat Agency, Dairy Farmers of Canada, Alberta Pulse Growers, and Western Canada Grain Growers, outside the submitted work; in addition, Dr. Chan has a patent No. Catherine Freeze reports personal fees from Dietitians of Canada and Government of Prince Edward Island, outside the submitted work. No other authors have anything to disclose. All content on guidelines. ca, CPG Apps and in our online store remains exactly the same. For questions, contact communications diabetes. Become a Member Order Resources Home About Contact DONATE. Next Previous. Key Messages Recommendations Figures Full Text References. Chapter Headings Introduction Ethnocultural Diversity Approach to Nutrition Therapy Energy Macronutrients Intensive Lifestyle Intervention Dietary Patterns Diets Emphasizing Specific Foods Special Considerations for People with Type 1 Diabetes and Type 2 Diabetes on Insulin Other Considerations Other Relevant Guidelines Author Disclosures. Key Messages People with diabetes should receive nutrition counselling by a registered dietitian. Nutrition therapy can reduce glycated hemoglobin A1C by 1. Reduced caloric intake to achieve and maintain a healthier body weight should be a treatment goal for people with diabetes with overweight or obesity. The macronutrient distribution is flexible within recommended ranges and will depend on individual treatment goals and preferences. Replacing high-glycemic-index carbohydrates with low-glycemic-index carbohydrates in mixed meals has a clinically significant benefit for glycemic control in people with type 1 and type 2 diabetes. Consistency in spacing and intake of carbohydrate intake and in spacing and regularity in meal consumption may help control blood glucose and weight. Intensive healthy behaviour interventions in people with type 2 diabetes can produce improvements in weight management, fitness, glycemic control and cardiovascular risk factors. A variety of dietary patterns and specific foods have been shown to be of benefit in people with type 1 and type 2 diabetes. People with diabetes should be encouraged to choose the dietary pattern that best aligns with their values, preferences and treatment goals, allowing them to achieve the greatest adherence over the long term. Key Messages for People with Diabetes It is natural to have questions about what food to eat. A registered dietitian can help you develop a personalized meal plan that considers your culture and nutritional preferences to help you achieve your blood glucose and weight management goals. Food is key in the management of diabetes and reducing the risk of heart attack and stroke. Try to prepare more of your meals at home and use fresh unprocessed ingredients. Try to prepare meals and eat together as a family. This is a good way to model healthy food behaviours to children and teenagers, which could help reduce their risk of becoming overweight or developing diabetes. With prediabetes and recently diagnosed type 2 diabetes, weight loss is the most important and effective dietary strategy if you have overweight or obesity. There are many strategies that can help with weight loss. The best strategy is one that you are able to maintain long term. Adoption of diabetes-friendly eating habits can help manage your blood glucose levels as well as reduce your risk for developing heart and blood vessel disease for those with either type 1 or type 2 diabetes. Select whole and less refined foods instead of processed foods, such as sugar-sweetened beverages, fast foods and refined grain products. Pay attention to both carbohydrate quality and quantity. Include low-glycemic-index foods, such as legumes, whole grains, and fruit and vegetables. These foods can help control blood glucose and cholesterol levels. Consider learning how to count carbohydrates as the quantity of carbohydrate eaten at one time is usually important in managing diabetes. Select unsaturated oils and nuts as the preferred dietary fats. Choose lean animal proteins. Select more vegetable protein. The style of eating that works well for diabetes may be described as a Mediterranean style diet, Nordic style diet, DASH diet or vegetarian style diet. All of these diets are rich in protective foods and have been shown to help manage diabetes and cardiovascular disease. They all contain the key elements of a diabetes-friendly diet. Introduction Nutrition therapy and counselling are an integral part of the treatment and self-management of diabetes. Ethnocultural Diversity Canada is a country rich in ethnocultural diversity. Approach to Nutrition Therapy Nutrition therapy should be individualized, regularly evaluated, reinforced in an intensive manner 11,12 , and should incorporate self-management education Figure 1 Nutritional management of hyperglycemia in type 2 diabetes. A1C , glycated hemoglobin. Macronutrients The ideal macronutrient distribution for the management of diabetes may vary, depending on the quality of the various macronutrients, the goals of the dietary treatment regimen and the individual's values and preferences. Carbohydrate CHO broadly include available CHO from starches and sugars and unavailable CHO from fibre. Glycemic Index The glycemic index GI provides an assessment of the quality of CHO-containing foods based on their ability to raise blood glucose BG Dietary fibre Dietary fibre includes the edible components of plant material that are resistant to digestion by human enzymes nonstarch polysaccharides and lignin, as well as associated substances. Sugars Added sugars, especially from fructose-containing sugars high fructose corn syrup [HFCS], sucrose and fructose , have become a focus of intense public health concern. Fat The DRIs do not specify an AI or RDA for total fat, monounsaturated fatty acids MUFA , saturated fatty acids SFA , or dietary cholesterol. Protein The DRIs specify a recommended dietary allowance RDA for protein of 0. Macronutrient substitutions The ideal macronutrient distribution for the management of diabetes can be individualized. Intensive Lifestyle Intervention Intensive lifestyle intervention ILI programs in diabetes usually consist of behavioural interventions combining dietary modification and increased physical activity. Dietary Patterns A variety of dietary patterns have been studied for people with prediabetes and diabetes. Mediterranean dietary patterns A Mediterranean diet primarily refers to a plant-based diet first described in the s Vegetarian dietary patterns Vegetarian dietary patterns include lacto-ovovegetarian, lactovegetarian, ovovegetarian and vegan dietary patterns. DASH and low-sodium dietary patterns Dietary approaches to reducing BP have focused on sodium reduction and the Dietary Approaches to Stop Hypertension DASH dietary pattern. Nordic dietary patterns The Nordic Diet was developed as a Nordic translation of the Mediterranean, Portfolio, DASH and NCEP dietary patterns, using foods typically consumed as part of a traditional Nordic diet in the context of Nordic Nutrition Recommendations Popular weight-loss diets Numerous popular weight-loss diets providing a range of macronutrient profiles are available to people with diabetes. Diets Emphasizing Specific Foods Dietary pulses and legumes Dietary pulses, the dried seeds of nonoil seed legumes, include beans, peas, chickpeas, and lentils. Fruit and vegetables Eating Well with Canada's Food Guide recommends up to 7 to 10 servings of fruit and vegetables per day Nuts Nuts include both peanuts a legume and tree nuts, such as almonds, walnuts, pistachios, pecans, Brazil nuts, cashews, hazelnuts, macadamia nuts and pine nuts. Whole grains Health Canada defines whole grains as those that contain all 3 parts of the grain kernel bran, endosperm, germ in the same relative proportions as they exist in the intact kernel. Dairy products Dairy products broadly include low- and full-fat milk, cheese, yogurt, other fermented products and ice cream. Special Considerations for People with Type 1 Diabetes and Type 2 Diabetes on Insulin For persons on insulin, consistency in CHO intake and spacing and regularity in meal consumption may help control BG levels — Other Considerations Non-nutritive sweeteners Sugar substitutes, which include high-intensity sweeteners and sugar alcohols, are regulated as food additives in Canada. Meal replacements Weight loss programs for people with diabetes may use partial meal replacement plans. Alcohol The same precautions regarding alcohol consumption in the general population apply to people with diabetes Vitamin and mineral supplements People with diabetes should be encouraged to meet their nutritional needs by consuming a well-balanced diet by following Eating Well with Canada's Food Guide Fasting and diabetes Within the lay literature, intermittent energy restriction strategies for weight loss have become more prevalent. Ramadan Traditionally, Muslims with type 1 and insulin-requiring type 2 diabetes have been exempted from participation in Ramadan fasting, due to concerns of hypo- and hyperglycemia. Food skills While there is no universally agreed upon definition of food skills, it is generally thought that they are interdependent technical, mechanical, conceptual and perceptual skills that are necessary to safely select and plan, prepare, and store nutritious and culturally-acceptable meals and snacks — Recommendations People with diabetes should receive nutrition counselling by a registered dietitian to lower A1C levels [Grade B, Level 2 3 , for those with type 2 diabetes; Grade D, Consensus, for type 1 diabetes] and to reduce hospitalization rates [Grade C, Level 3 8 ]. Nutrition education may be delivered in either a small group or one-on-one setting [Grade B, Level 2 18 ]. Group education should incorporate adult education principles, such as hands-on activities, problem solving, role playing and group discussions [Grade B, Level 2 19 ]. Individuals with diabetes should be encouraged to follow Eating Well with Canada's Food Guide in order to meet their nutritional needs [Grade D, Consensus]. In people with overweight or obesity with diabetes, a nutritionally balanced, calorie-reduced diet should be followed to achieve and maintain a lower, healthier body weight [Grade A, Level 1A 29,30 ]. An intensive healthy behaviour intervention program, combining dietary modification and increased physical activity, may be used to achieve weight loss, improve glycemic control and reduce CV risk [Grade A, Level 1A 30 ]. People with type 2 diabetes should maintain regularity in timing and spacing of meals to optimize glycemic control [Grade D, Level 4 ]. Adults with diabetes should select carbohydrate food sources with a low-GI to help optimize glycemic control [Grade B, Level 2 46,47 for type 1 diabetes; Grade B, Level 2 32,44 for type 2 diabetes], to improve LDL-C [Grade C, Level 3 49 ] and to decrease CV risk [Grade D, Level 4 52 ]. The following dietary patterns may be considered in people with type 2 diabetes, incorporating patient preferences, including: Mediterranean-style dietary pattern to reduce major CV events [Grade A, Level 1A ] and improve glycemic control [Grade B, Level 2 50, ]. Vegan or vegetarian dietary pattern to improve glycemic control [Grade B, Level 2 , ], body weight [Grade C, Level 3 ], and blood lipids, including LDL-C [Grade B, Level 2 ] and reduce myocardial infarction risk [Grade B, Level 2 ]. DASH dietary pattern to improve glycemic control [Grade C, Level 2 ], BP [Grade D, Level 4 — ], and LDL-C [Grade B, Level 2 , ] and reduce major CV events [Grade B, Level 3 ]. Dietary patterns emphasizing dietary pulses e. beans, peas, chickpeas, lentils to improve glycemic control [Grade B, Level 2 ], systolic BP [Grade C, Level 2 ] and body weight [Grade B, Level 2 ]. Dietary patterns emphasizing fruit and vegetables to improve glycemic control [Grade B, Level 2 , ] and reduce CV mortality [Grade C, Level 3 79 ]. Dietary patterns emphasizing nuts to improve glycemic control [Grade B, Level 2 ], and LDL-C [Grade B, Level 2 ]. Other Relevant Guidelines Chapter 7. Self-Management Education and Support Chapter Physical Activity and Diabetes Chapter Weight Management in Diabetes Chapter Complementary and Alternative Medicine for Diabetes Chapter Dyslipidemia Chapter Treatment of Hypertension Chapter Type 1 Diabetes in Children and Adolescents Chapter Type 2 Diabetes in Children and Adolescents Chapter Diabetes and Pregnancy Chapter Diabetes in Older People Chapter Type 2 Diabetes and Indigenous Peoples. Author Disclosures Dr. References Pastors JG,WarshawH, Daly A, et al. The evidence for the effectiveness of medical nutrition therapy in diabetes management. Diabetes Care ;— Pi-Sunyer FX, Maggio CA, McCarron DA, et al. Multicenter randomized trial of a comprehensive prepared meal program in type 2 diabetes. Diabetes Care ;—7. Franz MJ, Monk A, Barry B, et al. Effectiveness of medical nutrition therapy provided by dietitians in the management of non-insulin-dependent diabetes mellitus: A randomized, controlled clinical trial. J Am Diet Assoc ;— Kulkarni K, Castle G, Gregory R, et al. Nutrition practice guidelines for type 1 diabetes mellitus positively affect dietitian practices and patient outcomes. The Diabetes Care and Education Dietetic Practice Group. J Am Diet Assoc ;—70, quiz Gaetke LM, Stuart MA, Truszczynska H. A single nutrition counseling session with a registered dietitian improves short-term clinical outcomes for rural Kentucky patients with chronic diseases. Imai S, Kozai H, Matsuda M, et al. Intervention with delivery of diabetic meals improves glycemic control in patients with type 2 diabetes mellitus. J Clin Biochem Nutr ;— Huang MC, Hsu CC, Wang HS, et al. Prospective randomized controlled trial to evaluate effectiveness of registered dietitian-led diabetes management on glycemic and diet control in a primary care setting in Taiwan. Diabetes Care ;—9. Robbins JM, Thatcher GE, Webb DA, et al. Nutritionist visits, diabetes classes, and hospitalization rates and charges: The Urban Diabetes Study. Immigration and ethnocultural diversity in Canada. Ottawa: Statistics Canada, Report No. Gougeon R, Sievenpiper JL, Jenkins D, et al. The transcultural diabetes nutrition algorithm: A Canadian perspective. Int J Endocrinol ; Norris SL, Engelgau MM, Narayan KM. Effectiveness of self-management training in type 2 diabetes: A systematic review of randomized controlled trials. Ash S, Reeves MM, Yeo S, et al. Effect of intensive dietetic interventions onweight and glycaemic control in overweight men with Type II diabetes: A randomised trial. Int J Obes Relat Metab Disord ;— Vallis TM, Higgins-Bowser I, Edwards L. The role of diabetes education in maintaining lifestyle changes. Can J Diabetes ;— Willaing I, Ladelund S, Jorgensen T, et al. Nutritional counselling in primary health care: A randomized comparison of an intervention by general practitioner or dietician. Eur J Cardiovasc Prev Rehabil ;— Wilson C, Brown T, Acton K, et al. Effects of clinical nutrition education and educator discipline on glycemic control outcomes in the Indian health service. Diabetes Care ;—4. Brekke HK, Jansson PA, Lenner RA. Long-term 1- and 2-year effects of lifestyle intervention in type 2 diabetes relatives. Diabetes Res Clin Pract ;— Lemon CC, Lacey K, Lohse B, et al. Outcomes monitoring of health, behavior, and quality of life after nutrition intervention in adults with type 2 diabetes. Rickheim PL,Weaver TW, Flader JL, et al. Assessment of group versus individual diabetes education: A randomized study. TrentoM, Basile M, Borgo E, et al. A randomised controlled clinical trial of nurse-, dietitian- and pedagogist-led group care for the management of type 2 diabetes. J Endocrinol Invest ;— Pérez-Escamilla R, Hromi-Fiedler A, Vega-López S, et al. Impact of peer nutrition education on dietary behaviors and health outcomes among Latinos: A systematic literature review. J Nutr Educ Behav ;— Ralston JD, Hirsch IB, Hoath J, et al. Web-based collaborative care for type 2 diabetes: A pilot randomized trial. Marcy TR, Britton ML, Harrison D. Identification of barriers to appropriate dietary behavior in low-income patients with type 2 diabetes mellitus. Diabetes Ther ;— Christensen NK, Terry RD, Wyatt S, et al. Quantitative assessment of dietary adherence in patients with insulin-dependent diabetes mellitus. Toeller M, Klischan A, Heitkamp G, et al. Nutritional intake of IDDM patients from 30 centres in Europe. EURODIAB IDDM Complications Study Group. Diabetologia ;— Glazier RH, Bajcar J, Kennie NR, et al. A systematic review of interventions to improve diabetes care in socially disadvantaged populations. Anderson TJ, Grégoire J, Pearson GJ, et al. Can J Cardiol ;— Wing RR. Weight loss in the management of type 2 diabetes. In: Gerstein HC, Haynes B, eds. Evidence-based diabetes. Ontario: B. C, Decker Inc. Tuomilehto J, Lindström J, Eriksson JG, et al. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Engl J Med ;— KnowlerWC, Barrett-Connor E, Fowler SE, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. The Look Ahead Research Group, Wing RR. Long term effects of a lifestyle intervention on weight and cardiovascular risk factors in individuals with type 2 diabetes: Four year results of the Look AHEAD trial. Arch Intern Med ;— Food and Nutrition Board, Institute of Medicine of the National Academics. However, lowering total fat intake did not consistently improve glycemia or CVD risk factors in people with type 2 diabetes based on a systematic review 45 , several studies — , and a meta-analysis Benefit from a low-fat eating pattern appears to be mostly related to weight loss as opposed to the eating pattern itself , The Ornish and Pritikin lifestyle programs are two of the best known multicomponent very low-fat eating patterns. Three nonrandomized single-arm studies with 69 to participants lasting between 3 weeks and 2—3 years show that these multicomponent lifestyle intervention programs may improve glucose levels, weight, blood pressure, and HDL-C, with a mixed effect on triglycerides — Low-carbohydrate eating patterns, especially very low-carbohydrate VLC eating patterns, have been shown to reduce A1C and the need for antihyperglycemic medications. These eating patterns are among the most studied eating patterns for type 2 diabetes. In trials up to 6 months long, the low-carbohydrate eating pattern improved A1C more, and in trials of varying lengths, lowered triglycerides, raised HDL-C, lowered blood pressure, and resulted in greater reductions in diabetes medication Finally, in another meta-analysis comparing low-carbohydrate to high-carbohydrate eating patterns, the larger the carbohydrate restriction, the greater the reduction in A1C, though A1C was similar at durations of 1 year and longer for both eating patterns Table 4 provides a quick reference conversion of percentage of calories from carbohydrate to grams of carbohydrate based on number of calories consumed per day. Quick reference conversion of percent calories from carbohydrate shown in grams per day as reported in the research reviewed for this report. Because of theoretical concerns regarding use of VLC eating plans in people with chronic kidney disease, disordered eating patterns, and women who are pregnant, further research is needed before recommendations can be made for these subgroups. Adopting a VLC eating plan can cause diuresis and swiftly reduce blood glucose; therefore, consultation with a knowledgeable practitioner at the onset is necessary to prevent dehydration and reduce insulin and hypoglycemic medications to prevent hypoglycemia. No randomized trials were found in people with type 2 diabetes that varied the saturated fat content of the low- or very low-carbohydrate eating patterns to examine effects on glycemia, CVD risk factors, or clinical events. Most of the trials using a carbohydrate-restricted eating pattern did not restrict saturated fat; from the current evidence, this eating pattern does not appear to increase overall cardiovascular risk, but long-term studies with clinical event outcomes are needed — One small, 8-week study comparing the DASH eating pattern with a control group in people with type 2 diabetes indicated improved A1C, blood pressure, and cholesterol levels and weight loss with the DASH eating pattern, with no difference in triglycerides Another RCT compared the DASH eating pattern incorporating increased physical activity with a standard eating pattern without increased physical activity and found blood pressure was lower in the DASH and physical activity group, but A1C, weight, and lipids did not differ Research studies focused on a paleo eating pattern in adults with type 2 diabetes are small and few, ranging from 13—29 participants, lasting no longer than 3 months, and finding mixed effects on A1C, weight, and lipids — While intermittent fasting is not an eating pattern by definition, it has been included in this discussion because of increased interest from the diabetes community. Fasting means to go without food, drink, or both for a period of time. People fast for reasons ranging from weight management to upcoming medical visits to religious and spiritual practice. Intermittent fasting is a way of eating that focuses more on when you eat i. While it usually involves set times for eating and set times for fasting, people can approach intermittent fasting in many different ways. Published intermittent fasting studies involving diabetes and diabetes prevention demonstrate a variety of approaches, including restricting food intake for 18 to 20 h per day, alternate-day fasting, and severe calorie restriction for up to 8 consecutive days or longer Three of the studies — demonstrated that intermittent fasting, either in consecutive days of restriction or by fasting 16 h per day or more, may result in weight loss; however, there was no improvement in A1C compared with a nonfasting eating plan. One of the studies showed similar reductions in A1C, weight, and medication doses when 2 days of severe energy restriction were compared with chronic energy restriction. Another study looked at men with prediabetes and timing of food intake over a h period, with the intervention group restricted to a 6-h schedule of eating with final meal before 3 p. compared with a control schedule where eating occurred over a h period; improved insulin sensitivity, β-cell responsiveness, blood pressure, oxidative stress, and appetite were shown in the intervention group The safety of intermittent fasting in people with special health situations, including pregnancy and disordered eating, has not been studied. For adults with type 1 diabetes, no trials met the inclusion criteria for this Consensus Report related to Mediterranean-style, vegetarian or vegan, low-fat, low-carbohydrate, DASH, paleo, Ornish, or Pritikin eating patterns. A few studies have examined the impact of a VLC eating pattern for adults with type 1 diabetes. One randomized crossover trial with 10 participants examined a VLC eating pattern aiming for 47 g carbohydrate per day without a focus on calorie restriction compared with a higher carbohydrate eating pattern aiming for g carbohydrate per day for 1 week each. Participants following the VLC eating pattern had less glycemic variability, spent more time in euglycemia and less time in hypoglycemia, and required less insulin A single-arm person trial of a VLC eating pattern aimed at a goal of 75 g of carbohydrate or less per day found that weight, A1C, and triglycerides were reduced and HDL-C increased after 3 months, and after 4 years A1C was still lower and HDL-C was still higher than at baseline This evidence suggests that a VLC eating pattern may have potential benefits for adults with type 1 diabetes, but clinical trials of sufficient size and duration are needed to confirm prior findings. Until the evidence surrounding comparative benefits of different eating patterns in specific individuals strengthens, health care providers should focus on the key factors that are common among the patterns: 1 emphasize nonstarchy vegetables, 2 minimize added sugars and refined grains, and 3 choose whole foods over highly processed foods to the extent possible Multiple trials and meta-analyses have been published addressing the comparative effects of specific eating patterns for diabetes. Whereas no single eating pattern has emerged as being clearly superior to all others for all diabetes-related outcomes, evidence suggests certain eating patterns are better for specific outcomes. All eating patterns include a range of more-healthy versus less-healthy options: lentils and sugar-sweetened beverages are both considered part of a vegan eating pattern; fish and processed red meats are both considered part of a low-carbohydrate eating pattern; and removing the bun from a fast food burger might make it part of a paleo eating pattern but does not necessarily make it healthier. For adults with type 2 diabetes who are not taking insulin and who have limited health literacy or numeracy, or who are older and prone to hypoglycemia, a simple and effective approach to glycemia and weight management emphasizing appropriate portion sizes and healthy eating may be considered. People with prediabetes at a healthy weight should be considered for lifestyle intervention involving both aerobic and resistance exercise and a healthy eating plan such as a Mediterranean-style eating plan. People with diabetes and prediabetes should be screened and evaluated during DSMES and MNT encounters for disordered eating, and nutrition therapy should accommodate these disorders. There is substantial evidence indicating that weight loss is highly effective in preventing progression from prediabetes to type 2 diabetes and in managing cardiometabolic health in type 2 diabetes. Overweight and obesity are also increasingly prevalent in people with type 1 diabetes and present clinical challenges regarding diabetes treatment and CVD risk factors , Regular physical activity, which can contribute to both weight loss and prevention of weight regain, and behavioral strategies are also important components of lifestyle therapy for weight management 26 , 74 , 83 , — Structured weight loss programs with regular visits and use of meal replacements have been shown to enhance weight loss in people with diabetes — The combined data do not point to a threshold of weight loss for maximal clinical benefits in people with diabetes; rather, the greater the weight loss, the greater the benefits. The UK Prospective Diabetes Study UKPDS demonstrated that decreases in fasting glucose were correlated with degree of weight loss A meta-analysis conducted by Franz et al. Other meta-analyses focusing on nonmedicine or medicine-assisted weight loss interventions in type 2 diabetes support this finding — More recently, the Look AHEAD trial , compared standard DSMES to a more intensive lifestyle intervention and reduced-calorie eating plan. The intensive lifestyle intervention resulted in 8. A systematic review of the effectiveness of MNT revealed mixed weight loss outcomes in participants with type 1 and 2 diabetes 9. Similarly, while DSMES is a fundamental component of diabetes care 1 , it does not consistently produce sufficient weight loss to achieve optimal therapeutic benefits in people with diabetes , , For these reasons, diabetes MNT and DSMES should emphasize a targeted and concerted plan for weight management. The addition of metabolic surgery , weight loss medications , and glucose-lowering agents that promote weight loss can also be used as an adjunct to lifestyle interventions, resulting in greater weight loss that is maintained for a longer period of time. The data also support the position that weight loss therapy is effective at all phases of type 2 diabetes, both in individuals with recent-onset disease 1 , and in people with longer durations of diabetes treated with multiple diabetes medications , Regular physical activity by itself , or as part of a comprehensive lifestyle plan 26 , 74 , 83 , can prevent progression to type 2 diabetes in high-risk individuals. Studies have demonstrated beneficial effects of both aerobic and resistance exercise and additive benefits when both forms of exercise are combined — For purposes of weight loss, the ability to sustain and maintain an eating plan that results in an energy deficit, irrespective of macronutrient composition or eating pattern, is critical for success — Studies investigating specific weight loss eating plans using a broad range of macronutrient composition in people with diabetes have shown mixed results regarding effects on weight, A1C, serum lipids, and blood pressure , , , — As a result, the evidence does not identify one eating plan that is clearly superior to others and that can be generally recommended for weight loss for people with diabetes Individualized eating plans should support calorie reduction e. Weight loss interventions can be implemented in usual care settings and alternately in telehealth programs , In general, the intervention intensity and degree of individual participation in the program are important factors for successful weight loss — , The Look AHEAD trial and the Diabetes Remission Clinical Trial DiRECT highlight the potential for type 2 diabetes remission—defined as the maintenance of euglycemia complete remission or prediabetes level of glycemia partial remission with no diabetes medication for at least 1 year , —in people undergoing weight loss treatment. In the Look AHEAD trial, when compared with the control group, the intensive lifestyle arm resulted in at least partial diabetes remission in Diet composition may also play a role; in an RCT by Esposito et al. Obesity prevalence among people with type 1 diabetes has been significantly increasing — A recent study suggested obesity may promote progression to overt type 1 diabetes in at-risk individuals , but further confirmatory studies are needed. In addition, in people with established type 1 diabetes, presence of obesity can worsen insulin resistance, glycemic variability, microvascular disease complications, and cardiovascular risk factors — Therefore, weight management has been recommended as an essential component of care for people with type 1 diabetes who have overweight or obesity — There is a scarcity of evidence from RCTs evaluating weight loss interventions in type 1 diabetes. A retrospective nested-control study indicated that lifestyle-induced weight loss improved glycemia with a reduction in insulin doses compared with controls Individuals with type 1 diabetes and obesity may benefit from eating plans that result in an energy deficit and that are lower in total carbohydrate and GI and higher in fiber and lean protein Currently, adjunctive pharmacotherapy is not indicated for individuals with type 1 diabetes. However, there is preliminary evidence that in select individuals with type 1 diabetes and excess adiposity, newer pharmacotherapy i. In addition, metabolic surgery in appropriate candidates can decrease body weight and improve glycemia , When counseling individuals with diabetes and prediabetes about weight management, special attention also must be given to prevent, diagnose, and treat disordered eating. Disordered eating can make following an eating plan challenging Health care professionals should consider screening for disordered eating, refer to a mental health professional, and individualize nutrition therapy accordingly When sugar substitutes are used to reduce overall calorie and carbohydrate intake, people should be counseled to avoid compensating with intake of additional calories from other food sources. SSB consumption in the general population contributes to a significantly increased risk of type 2 diabetes, weight gain, heart disease, kidney disease, nonalcoholic liver disease, and tooth decay The U. Food and Drug Administration FDA has reviewed several types of sugar substitutes for safety and approved them for consumption by the general public, including people with diabetes In this report, the term sugar substitutes refers to high-intensity sweeteners, artificial sweeteners, nonnutritive sweeteners, and low-calorie sweeteners. These include saccharin, neotame, acesulfame-K, aspartame, sucralose, advantame, stevia, and luo han guo or monk fruit. Replacing added sugars with sugar substitutes could decrease daily intake of carbohydrates and calories. These dietary changes could beneficially affect glycemic, weight, and cardiometabolic control. However, an American Heart Association science advisory on the consumption of beverages containing sugar substitutes that was supported by the ADA concluded there is not enough evidence to determine whether sugar substitute use definitively leads to long-term reduction in body weight or cardiometabolic risk factors, including glycemia Using sugar substitutes does not make an unhealthy choice healthy; rather, it makes such a choice less unhealthy. If sugar substitutes are used to replace caloric sweeteners, without caloric compensation, they may be useful in reducing caloric and carbohydrate intake , although further research is needed to confirm these concepts Multiple mechanisms have been proposed for potential adverse effects of sugar substitutes, e. As people aim to reduce their intake of SSBs, the use of other alternatives, with a focus on water, is encouraged Sugar alcohols represent a separate category of sweeteners. Like sugar substitutes, sugar alcohols have been approved by the FDA for consumption by the general public and people with diabetes. Whereas sugar alcohols have fewer calories per gram than sugars, they are not as sweet. Therefore, a higher amount is required to match the degree of sweetness of sugars, generally bringing the calorie content to a level similar to that of sugars Use of sugar alcohols needs to be balanced with their potential to cause gastrointestinal effects in sensitive individuals. Currently, there is little research on the potential benefits of sugar alcohols for people with diabetes It is recommended that adults with diabetes or prediabetes who drink alcohol do so in moderation one drink or less per day for adult women and two drinks or less per day for adult men. Educating people with diabetes about the signs, symptoms, and self-management of delayed hypoglycemia after drinking alcohol, especially when using insulin or insulin secretagogues, is recommended. The importance of glucose monitoring after drinking alcohol beverages to reduce hypoglycemia risk should be emphasized. It is important that health care providers counsel people with diabetes about alcohol consumption and encourage moderate and sensible use for people choosing to consume alcohol. One alcohol-containing beverage is defined as oz beer, 5-oz wine, or 1. Starting with one drink per day, risk for reduced adherence to self-care and healthy lifestyle behaviors has been reported with increasing alcohol consumption Despite the potential glycemic and cardiovascular benefits of moderate alcohol consumption, alcohol intake may place people with diabetes at increased risk for delayed hypoglycemia , — This is particularly relevant for those using insulin or insulin secretagogues who can experience delayed nocturnal or fasting hypoglycemia after evening alcohol consumption. Consuming alcohol with food can minimize the risk of nocturnal hypoglycemia , It is essential that people with diabetes receive education regarding the recognition and management of delayed hypoglycemia and the potential need for more frequent glucose monitoring after consuming alcohol , Comprehensive reviews and meta-analyses suggest a protective effect of moderate alcohol intake on the risk of developing type 2 diabetes, with a higher rate of diabetes in alcohol abstainers and heavy consumers , — Knott et al. A meta-analysis and systematic review that examined the effects of specific types of alcohol beverage consumption and the incidence of type 2 diabetes found that wine consumption was associated with significantly lower diabetes risk, as compared with a smaller reduction in risk with beer and spirits. While epidemiologic evidence shows a correlation between alcohol consumption and risk of diabetes, the evidence does not suggest that providers should advise abstainers to start consuming alcohol. Without underlying deficiency, the benefits of multivitamins or mineral supplements on glycemia for people with diabetes or prediabetes have not been supported by evidence, and therefore routine use is not recommended. It is recommended that MNT for people taking metformin include an annual assessment of vitamin B12 status with guidance on supplementation options if deficiency is present. The routine use of chromium or vitamin D micronutrient supplements or any herbal supplements, including cinnamon, curcumin, or aloe vera, for improving glycemia in people with diabetes is not supported by evidence and is therefore not recommended. Scientific evidence does not support the use of dietary supplements in the form of vitamins or minerals to meet glycemic targets or improve CVD risk factors in people with diabetes or prediabetes, in the absence of an underlying deficiency — People with diabetes not achieving glucose targets may have an increased risk of micronutrient deficiencies , so maintaining a balanced intake of food sources that provide at least the recommended daily allowance for nutrients and micronutrients is essential For special populations, including women planning pregnancy, people with celiac disease, older adults, vegetarians, and people following an eating plan that restricts overall calories or one or more macronutrients, a multivitamin supplement may be justified A systematic review on the effect of chromium supplementation on glucose and lipid metabolism concluded that evidence is limited by poor study quality and heterogeneity in methodology and results , Evidence from clinical studies that evaluated magnesium , and vitamin D — supplementation to improve glycemia in people with diabetes is likewise conflicting. However, evidence is emerging that suggests that magnesium status may be related to diabetes risk in people with prediabetes It is important to consider that nutritional supplements and herbal products are not standardized or regulated , Health care providers should ask about the use of supplements and herbal products, and providers and people with or at risk for diabetes should discuss the potential benefit of these products weighed against the cost and possible adverse effects and drug interactions. The variability of herbal and micronutrient supplements makes research in this area challenging and makes it difficult to conclude effectiveness. To date, there is limited evidence supporting the addition of herbal supplements to manage glycemia. Because of public interest and the lack of conclusive data, the National Center for Complementary and Integrative Health at the National Institutes of Health aims to answer important public health and scientific questions by funding and conducting research on complementary medicine. Metformin is associated with vitamin B12 deficiency, with a recent systematic review recommending that annual blood testing of vitamin B12 levels be considered in metformin-treated people, especially in those with anemia or peripheral neuropathy This study found that even in the absence of anemia, B12 deficiency was prevalent. The exact cause of B12 deficiency in people taking metformin is not known, but some research points to malabsorption caused by metformin, with other studies suggesting improvements in B12 status with calcium supplementation — The standard of treatment has been B12 injections, but new research suggest that high-dose oral supplementation may be as effective , More research is needed in this area. All RDNs providing MNT in diabetes care should assess and monitor medication changes in relation to the nutrition care plan. For individuals with type 1 diabetes, intensive insulin therapy using the carbohydrate counting approach can result in improved glycemia and is recommended. For adults using fixed daily insulin doses, consistent carbohydrate intake with respect to time and amount, while considering the insulin action time, can result in improved glycemia and reduce the risk for hypoglycemia. A cautious approach to increasing mealtime insulin doses is suggested; continuous glucose monitoring CGM or self-monitoring of blood glucose SMBG should guide decision-making for administration of additional insulin. RDNs providing MNT in diabetes care should assess and monitor medication changes in relation to the nutrition care plan. Along with other diabetes care providers, RDNs who possess advanced practice training and clinical expertise should take an active role in facilitating and maintaining organization-approved diabetes medication protocols. For people with type 1 diabetes using basal-bolus insulin therapy, a primary focus for MNT should include guidance on adjusting insulin based on anticipated dietary intake, particularly carbohydrate intake 9 , — ; recent or expected physical activity; and glucose data. Intensive insulin management education programs that include nutrition therapy have been shown to improve A1C 9 , , , — and quality of life 9 , For people using fixed daily insulin doses, carbohydrate intake on a day-to-day basis should be consistent with respect to time and amount per meal 9 , , Checking glucose 3 h after eating may help to determine if additional insulin adjustments i. Because these insulin dosing algorithms require determination of anticipated nutrient intake to calculate the mealtime dose, health literacy and numeracy should be evaluated. The effectiveness of insulin dosing decisions should be confirmed with a structured approach to SMBG or CGM to evaluate individual responses and guide insulin dose adjustments. In general, replacing saturated fat with unsaturated fats reduces both total cholesterol and LDL-C and also benefits CVD risk. In type 2 diabetes, counseling people on eating patterns that replace foods high in carbohydrate with foods lower in carbohydrate and higher in fat may improve glycemia, triglycerides, and HDL-C; emphasizing foods higher in unsaturated fat instead of saturated fat may additionally improve LDL-C. The recommendation for the general public to eat a serving of fish particularly fatty fish at least two times per week is also appropriate for people with diabetes. Nutrition therapy that includes the development of an eating plan designed to optimize blood glucose trends, blood pressure, and lipid profiles is important in the management of diabetes and can lower the risk of CVD, CHD, and stroke 9. Findings from clinical trials support the role of nutrition therapy for achieving glycemic targets and decreasing various markers of cardiovascular and hypertension risk 9 , 24 , — There has been increasing research examining the effects of high-fat, low-carbohydrate eating patterns on cardiometabolic risk factors, with two systematic reviews showing benefits of low-carbohydrate eating plans compared with low-fat eating plans on glycemic and CVD risk parameters in the treatment of type 2 diabetes see the section Low-Carbohydrate or Very Low-Carbohydrate Eating Patterns , The scientific rationale for decreasing saturated fat in the diet is based on the effect of saturated fat in raising LDL-C, a contributing factor in atherosclerosis In a Presidential Advisory on dietary fat and CVD, the American Heart Association concluded that lowering intake of saturated fat and replacing it with unsaturated fats, especially polyunsaturated fats, will lower the incidence of CVD Subgrouping of the studies suggested that benefit occurred by replacing saturated fat with polyunsaturated fat but not with carbohydrate or protein In a systematic review of observational studies, saturated fats were not associated with all-cause mortality, CVD, CHD, ischemic stroke, or type 2 diabetes, but limitations common to observational studies were noted The replacement of saturated fat with monounsaturated or polyunsaturated fat in food or replacement of trans fat with monounsaturated fat in food was inversely associated with CVD In general, replacing saturated fat with unsaturated fats, especially polyunsaturated fat, significantly reduces both total cholesterol and LDL-C, and replacement with monounsaturated fat from plant sources, such as olive oil and nuts, reduces CVD risk. Replacing saturated fat with carbohydrate also reduces total cholesterol and LDL-C, but significantly increases triglycerides and reduces HDL-C , A recent meta-analysis of nine RCTs showed that, compared with control, the Mediterranean-style eating pattern, which is high in monounsaturated fats from plant sources such as olive oil and nuts, improved outcomes of glycemia, body weight, and cardiovascular risk factors in participants with type 2 diabetes A systematic review and meta-analysis of 24 studies and including 1, participants compared the effect of eating plans high in monounsaturated fat with that of eating plans high in carbohydrates. The eating plans high in monounsaturated fat showed significant reductions in fasting glucose, triglycerides, body weight, and systolic blood pressure along with significant increases in HDL-C. The systematic review and meta-analysis also reviewed four studies with a total of 44 participants comparing eating plans high in monounsaturated fat with those high in polyunsaturated fat. The eating plans high in monounsaturated fat led to a significant reduction in fasting plasma glucose As is recommended for the general public, an increase in foods containing the long-chain omega-3 fatty acids EPA and docosahexaenoic acid DHA , such as are found in fatty fish, 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 , For people following a vegetarian or vegan eating pattern, omega-3 α-linoleic acid ALA found in plant foods such as flax, walnuts, and soy are reasonable replacements for foods high in saturated fat and may provide some CVD benefits, though the evidence is inconclusive. Evidence does not conclusively support recommending omega-3 EPA and DHA supplements for all people with diabetes for the prevention or treatment of cardiovascular events. Omega-3 fatty acid supplements have not reduced CVD events or mortality in randomized trials but may have utility in people who require triglyceride reduction , A meta-analysis of seven RCTs showed that increased trans fat intake did not result in changes in glucose, insulin, or triglyceride concentrations but led to an increase in total and LDL-C and a decrease in HDL-C concentrations Trans fats also have been associated with all-cause mortality, total CHD, and CHD mortality Some studies measuring urine sodium excretion in people with type 1 and type 2 diabetes have shown increased mortality associated with the lowest sodium intakes. When individualizing sodium intake recommendations, careful consideration must be given to issues such as food preference, palatability, availability, and additional cost of fresh or specialty low-sodium products In individuals with diabetes and non—dialysis-dependent diabetic kidney disease DKD , reducing the amount of dietary protein below the recommended daily allowance 0. Historically, low-protein eating plans were advised to reduce albuminuria and progression of chronic kidney disease in people with DKD, typically with improvements in albuminuria but no clear effect on estimated glomerular filtration rate. In addition, there is some indication that a low-protein eating plan may lead to malnutrition in individuals with DKD — The average daily level of protein intake for people with diabetes without kidney disease is typically 1—1. Evidence does not suggest that people with DKD need to restrict protein intake to less than the average protein intake. For people with DKD and macroalbuminuria, changing to a more soy-based source of protein may improve CVD risk factors but does not appear to alter proteinuria , Correcting hyperglycemia is one strategy for the management of gastroparesis, as acute hyperglycemia delays gastric emptying. Consultation by an RDN knowledgeable in the management of gastroparesis is helpful in setting and maintaining treatment goals Treatment goals include managing and reducing symptoms; correcting fluid, electrolyte, and nutritional deficiencies and glycemic imbalances; and addressing the precipitating cause s with appropriate drug therapy Correcting hyperglycemia is one strategy for the management of gastroparesis, as acute hyperglycemia delays gastric emptying , Modification of food and beverage intake is the primary management strategy, especially among individuals with mild symptoms. People with gastroparesis may find it helpful to eat small, frequent meals. Replacing solid food with a greater proportion of liquid calories to meet individualized nutrition requirements may be helpful because consuming solid food in large volumes is associated with longer gastric emptying times , Large meals can also decrease the lower esophageal sphincter pressure, which may cause gastric reflux, providing further aggravation Many of the foods typically recommended for people with diabetes, such as leafy green salads, raw vegetables, beans, and fresh fruits, and other food like fatty or tough meat, can be some of the most difficult foods for the gastroparetic stomach to grind and empty , Notably, the majority of nutrition therapy interventions for gastroparesis are based on the knowledge of the pathophysiology and clinical judgment rather than empirical research The use of an insulin pump is another option for individuals with type 1 diabetes and insulin-requiring type 2 diabetes with gastroparesis A small but positive month trial reported a 1. An insulin pump can be used to provide consistent basal insulin infusion, as well as the ability to modify mealtime insulin delivery doses as needed. The variable bolus feature allows the user to administer a portion of the meal bolus in an extended fashion over a longer period of time Use of this feature may help to decrease the risk of postprandial hyperglycemia as well as hypoglycemia. When an individual with gastroparesis falls below target weight, nutrition support in the form of oral for acute exacerbation of symptoms , enteral, or parenteral nutrition should be considered Studies using personalized nutrition approaches to examine genetic, metabolomic, and microbiome variations have not yet identified specific factors that consistently improve outcomes in type 1 diabetes, type 2 diabetes, or prediabetes. Currently, use of nutrition counseling approaches aimed at personalizing guidance based on genetic, metabolomic, and microbiome information is an area of intense research. Testing has become available commercially, with direct-to-consumer advertising. Some intriguing research has shown, for example, the wide interpersonal variability in blood glucose response to standardized meals that could be predicted by clinical and microbiome profiles At this point, however, no clear conclusions can be drawn regarding their utility owing to wide variations in the markers used for predicting outcomes, in the populations and nutrients studied, and in the associations found. Ideally, an eating plan should be developed in collaboration with the person with prediabetes or diabetes and an RDN through participation in diabetes self-management education when the diagnosis of prediabetes or diabetes is made. Regular follow-up with a diabetes health care provider is also critical to adjust other aspects of the treatment plan as indicated. Unfortunately, national data indicate that most people with diabetes do not receive any nutrition therapy or formal diabetes education 4 , 9 , 16 , providing in-person or technology-enabled diabetes nutrition therapy and education integrated with medical management 9 , 12 , 13 , 15 , 16 , 19 , 22 , — , — ;. engineering solutions that include two-way communication between the individual and his or her health care team to provide individualized feedback and tailored education based on the analyzed patient-generated health data 38 , , ;. increasing the use of community health workers and peer coaches to provide culturally appropriate, ongoing support and clinically linked care coordination and improve the reach of MNT and DSMES 15 , 19 , 23 , 38 , , Evaluating nutrition evidence is complex given that multiple dietary factors influence glycemic management 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 knowledge gaps continue to exist and further research on nutrition and eating patterns is needed in individuals with type 1 diabetes, type 2 diabetes, and prediabetes. Future studies should address. the impact of different eating patterns compared with one another, controlling for supplementary advice such as stress reduction, physical activity, or smoking cessation ;. the impact of weight loss on other outcomes which eating plans are beneficial only with weight loss, which can show benefit regardless of weight loss ;. how cultural or personal preferences, psychological supports, co-occurring conditions, socioeconomic status, food insecurity, and other factors impact being consistent with an eating plan and its effectiveness;. the need for increased length and size of studies, to better understand long-term impacts on clinically relevant outcomes;. comparisons of different delivery methods aided by technology e. ongoing cost-effectiveness studies that will further support coverage by third-party payers or bundling services into evolving value-based care and payment models. The authors acknowledge Mindy Saraco Managing Director, Medical Affairs, ADA for her help with the development of the Consensus Report. The authors acknowledge the invited peer reviewers who provided comments on an earlier draft of this report: Kelli Begay Indian Health Service, Rockville, MD , Guoxun Chen University of Tennessee, Knoxville, TN , Frank Hu Harvard T. Duality of Interest. The authors disclosed all potential financial conflicts of interest with industry. These disclosures were discussed at the onset of the consensus statement development process. The ADA uses general revenues to fund development of its consensus reports and does not rely on industry support for these purposes. reports honorarium from the Academy of Nutrition and Dietetics and the ADA outside of the submitted work. reports personal fees from Novo Nordisk, Merck, Amgen, Gilead, BOYDSense, the American Medical Group Association, and Janssen and grants from Sanofi, Pfizer, Merck, and Novo Nordisk outside of the submitted work. reports personal fees from Sunstar Foundation outside of the submitted work. was previously employed by the ADA. reports grants from the National Institutes of Health and internal University of Michigan grants. reports a consulting relationship with dietdoctor. com, which began after the Consensus Report was submitted to Diabetes Care. No other potential conflicts of interest relevant to this article were reported. Author Contributions. All authors were responsible for drafting the Consensus Report and revising it critically for important intellectual content. All authors approved the version to be published. Sign In or Create an Account. Search Dropdown Menu. header search search input Search input auto suggest. filter your search All Content All Journals Diabetes Care. Advanced Search. User Tools Dropdown. Sign In. Skip Nav Destination Close navigation menu Article navigation. Volume 42, Issue 5. Previous Article Next Article. Data Sources, Searches, and Study Selection. EATING PATTERNS. MNT and Antihyperglycemic Medications Including Insulin. Article Information. Article Navigation. Continuing Evolution of Nutritional Therapy for Diabetes April 15 Nutrition Therapy for Adults With Diabetes or Prediabetes: A Consensus Report Alison B. Evert ; Alison B. This Site. Google Scholar. Michelle Dennison ; Michelle Dennison. Christopher D. Gardner ; Christopher D. |
| Exercise and the Institute of Medicine recommendations for nutrition | Am J Physiol Endocrinol Metab 6 : E Effect of fruits and vegetables on metabolic syndrome: A systematic reviewand meta-analysis of randomized controlled trials. Thus, the importance of timing may be largely dependent on when a pre-workout meal was consumed, the size and composition of that meal and the total daily protein in the diet. A systematic review, including meta-analyses, of the evidence from human and animal studies. There are many strategies that can help with weight loss. Am J Phys Regul Integr Comp Phys. |
| Meal Frequency and Nutrient Distribution: What is Ideal for Body Composition? | On both diets, weekly or biweekly nutrition and cooking instruction was provided by a dietitian or cooking instructor Similarly, a calorie-restricted vegetarian diet was shown to improve BMI and LDL-C more than a conventional diet in people with type 2 diabetes Subsequent systematic reviews and meta-analyses of the available randomized controlled trials have shown that vegetarian and vegan dietary patterns resulted in clinically meaningful improvements in A1C and FBG in people with type 1 and type 2 diabetes over 4 to 74 weeks , , as well as body weight and blood lipids in people with and without diabetes over 3 to 74 weeks. A systematic review and meta-analysis of prospective cohort and cross-sectional observational studies showed a protective association between vegetarian dietary patterns and incident fatal and nonfatal CHD Dietary approaches to reducing BP have focused on sodium reduction and the Dietary Approaches to Stop Hypertension DASH dietary pattern. The DASH dietary pattern does not target sodium reduction but rather emphasizes vegetables, fruits and low-fat dairy products, and includes whole grains, poultry, fish and nuts. It contains smaller amounts of red and processed meat, sweets, sugar-containing beverages, total and saturated fat, and cholesterol, and larger amounts of potassium, calcium, magnesium, dietary fibre and protein than typical Western diets , The DASH dietary pattern has been shown to lower systolic and diastolic BP compared with a typical American diet matched for sodium intake in people with and without hypertension, inclusive of people with well-controlled diabetes , In addition to BP-lowering benefit, a systematic review and meta-analysis of randomized controlled trials showed that a DASH dietary pattern lowered lipids, including LDL-C in people with and without hypertension, some of whom had metabolic syndrome or diabetes A systematic review and meta-analysis of prospective cohort studies that included people with diabetes showed that adherence to a DASH dietary pattern was associated with a reduction in incident CVD These small effects combine to provide a meaningful overall reduction in LDL-C lowering. Although the Portfolio dietary pattern has not been formally tested in people with diabetes, each component has been shown individually to lower LDL-C in systematic reviews and meta-analyses of randomized controlled trials inclusive of people with diabetes 57,59—61,— The results of the Combined Portfolio Diet and Exercise Study PortfolioEx trial , a 3-year multicentre randomized controlled trial of the effect of the Portfolio Diet plus exercise on atherosclerosis, assessed by magnetic resonance imaging MRI in high CV risk people ClinicalTrials. gov Identifier, NCT , will provide important new data in people with diabetes, as approximately one-half of the participants will have type 2 diabetes. The Nordic Diet was developed as a Nordic translation of the Mediterranean, Portfolio, DASH and NCEP dietary patterns, using foods typically consumed as part of a traditional Nordic diet in the context of Nordic Nutrition Recommendations The Nordic Diet has not been studied in people with diabetes; however, 3 high-quality randomized controlled trials have studied the effect of a Nordic Diet on glycemic control and other relevant cardiometabolic outcomes in people with central obesity or metabolic syndrome. These have shown improvements in body weight, insulin resistance, and lipids, including the therapeutically relevant LDL-C and non-HDL-C — Numerous popular weight-loss diets providing a range of macronutrient profiles are available to people with diabetes. Furthermore, the Mediterranean-style diet had a more favourable effect on FPG at 2 years in the subgroup of participants with type 2 diabetes Dietary pulses, the dried seeds of nonoil seed legumes, include beans, peas, chickpeas, and lentils. This taxonomy does not include the oil-seed legumes soy, peanuts or fresh legumes peas, beans. A systematic review and meta-analysis of prospective cohort studies, inclusive of people with diabetes, showed that the intake of 4 weekly g servings of legumes is associated with decreased incident total CHD Eating Well with Canada's Food Guide recommends up to 7 to 10 servings of fruit and vegetables per day Individual randomized controlled trials have shown that supplementation with fresh or freeze dried fruits improves A1C over 6 to 8 weeks in individuals with type 2 diabetes , A novel and simple technique of encouraging intake of vegetables first and other CHOs last at each meal was successful in achieving better glycemic control A1C than an exchange-based meal plan after 24 months of follow up in people with type 2 diabetes A systematic review and meta-analysis of randomized controlled trials also showed that fruit and vegetables provided as either foods or supplements improved diastolic BP over 6 weeks to 6 months in individuals with the metabolic syndrome, some of whom had prediabetes In people with type 1 and type 2 diabetes, an intervention to increase the intake of fruit, vegetables and dairy that only succeeded in increasing the intake of fruits and vegetables, led to a similar improvement in diastolic blood pressure and to a clinically meaningful regression in carotid intima medial thickness over 1 year Although there is a need to understand better the advantages of different fruit and vegetables in people with diabetes, higher intake of total fruit and vegetables remains an important part of all healthy dietary patterns. Nuts include both peanuts a legume and tree nuts, such as almonds, walnuts, pistachios, pecans, Brazil nuts, cashews, hazelnuts, macadamia nuts and pine nuts. An individual patient-level meta-analysis of 25 nut intervention trials of the effect of nuts on lipid outcomes in people with normolipidemia or hypercholesterolemia including 1 trial in people with type 2 diabetes also showed a dose-dependent reduction in blood lipids, including the established therapeutic target LDL-C A systematic review and meta-analysis of prospective cohort studies in people with and without diabetes also showed that the intake of 4 weekly Despite concerns that the high energy density of nuts may contribute to weight gain, systematic reviews of randomized controlled trials have failed to show an adverse effect of nuts on body weight and measures of adiposity when nuts are consumed as part of balanced, healthy dietary patterns , Health Canada defines whole grains as those that contain all 3 parts of the grain kernel bran, endosperm, germ in the same relative proportions as they exist in the intact kernel. Health Canada recommends that at least half of all daily grain servings are consumed from whole grains Sources of whole grains include both the cereal grains e. wheat, rice, oats, barley, corn, wild rice, and rye and pseudocereal grains e. quinoa, amaranth and buckwheat but not oil seeds e. soy, flax, sesame seeds, poppy seeds. Systematic reviews and meta-analyses of randomized controlled trials have shown that whole grain interventions, specifically with whole grain sources containing the viscous soluble fibre beta-glucan, such as oats and barley, improve lipids, including TG and LDL-C, in people with and without diabetes over 2 to 16 weeks of follow up Whole grains have also been shown to improve glycemic control. Whole grains from barley have shown improvements in fasting glucose in people with and without diabetes 57 and whole grains from oats have shown improvements in A1C and FPG in the subgroup with type 2 diabetes In contrast, these advantages have not been seen for whole grain sources from whole wheat or wheat bran in people with type 2 diabetes 56,66, Systematic reviews and meta-analyses of prospective cohort studies have shown a protective association of total whole grains where wheat is the dominant source and total cereal fibre as a proxy of whole grains with incident CHD in people with and without diabetes 69, Although higher intake of all whole grains remains advisable especially from oats and barley , more research is needed to understand the role of different sources of whole grains in people with diabetes. Dairy products broadly include low- and full-fat milk, cheese, yogurt, other fermented products and ice cream. Evidence for the benefit of specific dairy products as singular interventions in the management of diabetes is inconclusive. Systematic reviews and meta-analyses of randomized controlled trials of the effect of diets rich in either low- or full-fat dairy products have not shown any clear advantages for body weight, body fat, waist circumference, FPG or BP across individuals with different metabolic phenotypes otherwise healthy, with overweight or obesity, or metabolic syndrome , The comparator, however, may be an important consideration. Individual randomized controlled trials, which have assessed the effect of dairy products in isocaloric substitution with SSBs and foods, have shown advantages for visceral adipose tissue, systolic blood pressure and triglycerides in individuals with overweight or obesity over 6 months and markers of insulin resistance in people with prediabetes over 6 weeks Other evidence from observational studies is suggestive of a weight loss and CV benefit. Large pooled analyses of the Harvard cohorts have shown that higher intakes of yogurt are associated with decreased body weight over 12 to 20 years of follow up in people with and without diabetes Systematic reviews and meta-analyses of prospective cohort studies inclusive of people with diabetes have also shown a protective association of cheese with incident CHD; low-fat dairy products with incident CHD; and total, low-fat, and full-fat dairy products, and total milk with incident stroke over 5 to 26 years of follow up , For persons on insulin, consistency in CHO intake and spacing and regularity in meal consumption may help control BG levels — Inclusion of snacks as part of a person's meal plan should be individualized based on meal spacing, metabolic control, treatment regimen and risk of hypoglycemia, and should be balanced against the potential risk of weight gain , The nutritional recommendations that reduce CV risk apply to both type 1 and type 2 diabetes. Studies have shown that people with type 1 diabetes tend to consume diets that are low in fibre, and high in protein and saturated fat In addition, it was shown in the Diabetes Control and Complications Trial DCCT , intensively treated individuals with type 1 diabetes showed worse diabetes control with diets high in total and saturated fat and low in CHO Meals high in fat and protein may require additional insulin and, for those using CSII, the delivery of insulin may be best given over several hours Algorithms for improved bolusing are under investigation. Heavy CHO loads greater than 60 g have been shown to result in greater glucose area under the curve and some risk of late postprandial hypoglycemia People with type 1 diabetes or type 2 diabetes requiring insulin, using a basal-bolus regimen, should adjust their insulin based on the CHO content of their meals, and inject their insulin within 15 minutes of eating with rapid-acting insulin analogues and just prior to and if required up to 20 minutes after eating with faster-acting insulin aspart for optimal match between rapid insulin and glycemic meal rise see Glycemic Management of Type 1 Diabetes in Adults chapter, p. Intensive insulin therapy regimens that include multiple injections of rapid-acting insulin matched to CHO allow for flexibility in meal size and frequency , Improvements in A1C, BG and quality of life, as well as less requirement for insulin, can be achieved when individuals with type 1 diabetes or type 2 diabetes receive education on matching insulin to CHO content e. CHO counting , In doing so, dietary fibre and sugar alcohol should be subtracted from total CHO. They also improved individual quality of life and treatment satisfaction Sugar substitutes, which include high-intensity sweeteners and sugar alcohols, are regulated as food additives in Canada. Health Canada has set acceptable daily intake ADI values, which are expressed on a body weight basis and are considered safe daily intake levels over a lifetime Table 2. These levels are considered high and are rarely achieved. Most have been shown to be safe when used by people with diabetes — ; however, there are limited data on the newer sweeteners, such as neotame and thaumatin in people with diabetes. Although systematic reviews and meta-analyses of prospective cohort studies inclusive of people with diabetes have shown an adverse association of non-nutritive sweetened beverages with weight gain, CVD and stroke, it is well recognized that these data are at high risk of reverse causality , The evidence from systematic reviews and meta-analyses of randomized controlled trials, which give a better protection against bias, have shown a weight loss benefit when non-nutritive sweeteners are used to displace excess calories from added sugars especially from SSBs in overweight children and adults without diabetes , a benefit that has been shown to be similar to that seen with other interventions intended to displace excess calories from added sugars, such as water Sugar alcohols approved for use in Canada include: erythritol, isomalt, lactitol, maltitol, mannitol, sorbitol, xylitol. There is no ADI for sugar alcohols except for erythritol as their use is considered self-limiting due to the potential for adverse gastrointestinal symptoms. They vary in the degree to which they are absorbed, and their conversion rate to glucose is slow, variable and usually minimal, and may have no significant effect on BG. Thus, matching rapid-acting insulin to the intake of sugar alcohols is not recommended Weight loss programs for people with diabetes may use partial meal replacement plans. Commercially available, portion-controlled, vitamin- and mineral-fortified meal replacement products usually replace 1 or 2 meals per day in these plans. Randomized controlled feeding trials have shown partial meal replacement plans result in comparable or increased , weight loss compared with conventional reduced-calorie diets for up to 1 year with maintenance up to 86 weeks in people with type 2 diabetes and overweight. This weight loss results in greater improvements in glycemic control over 3 months to 34 weeks , and reductions in the need for antihyperglycemic medications up to 1 year without an increase in hypoglycemic or other adverse events — Meal replacements with differing macronutrient compositions designed for people with diabetes have shown no clear advantage, although studies are lacking , The same precautions regarding alcohol consumption in the general population apply to people with diabetes For people with type 1 diabetes, moderate consumption of alcohol with, or 2 or 3 hours after, an evening meal may result in delayed hypoglycemia the next morning after breakfast or as late as 24 hours after alcohol consumption , and may impede cognitive performance during mild hypoglycemia The same concern may apply to sulphonylurea- and insulin-treated individuals with type 2 diabetes Health-care professionals should discuss alcohol use with people with diabetes to inform them of the potential weight gain and risks of hypoglycemia People with diabetes should be encouraged to meet their nutritional needs by consuming a well-balanced diet by following Eating Well with Canada's Food Guide Routine vitamin and mineral supplementation is generally not recommended. Supplementation with folic acid 0. The need for further vitamin and mineral supplements should be assessed on an individual basis. As vitamin and mineral supplements are regulated as natural health products NHP in Canada, the evidence for their therapeutic role in diabetes has been reviewed in the Complementary and Alternative Medicine for Diabetes chapter, p. Within the lay literature, intermittent energy restriction strategies for weight loss have become more prevalent. To date, there is limited evidence for these approaches with people with type 2 diabetes. Traditionally, Muslims with type 1 and insulin-requiring type 2 diabetes have been exempted from participation in Ramadan fasting, due to concerns of hypo- and hyperglycemia. Similarly, people on non-insulin antihyperglycemic agents associated with hypoglycemia are also considered high risk for fasting. People with diabetes who wish to participate in Ramadan fasting are encouraged to consult with their diabetes health-care team 1 to 2 months prior to the start of Ramadan. While evidence for the impact of Ramadan fasting in individuals with type 1 diabetes is limited, the literature suggests that in people with well-controlled type 1 diabetes, complications from fasting are rare. A reduction in the total daily dose of insulin can reduce the incidence of hypoglycemia. CSII therapy or the use of multiple daily injections with rapid-acting insulin taken with meals and basal insulin, combined with frequent self-monitoring of blood glucose SMBG can help reduce the risk of hypo- and hyperglycemia. Individuals with a history of severe hypoglycemia or hypoglycemia unawareness should be discouraged from participating in Ramadan fasting , pdf While there is no universally agreed upon definition of food skills, it is generally thought that they are interdependent technical, mechanical, conceptual and perceptual skills that are necessary to safely select and plan, prepare, and store nutritious and culturally-acceptable meals and snacks — Several studies suggest that food preparation and cooking skills are declining globally ,, Over the past several decades, in Canada, there has been an increase in processed, pre-prepared and convenience foods being purchased and assembled rather than meals being prepared using whole, basic ingredients To our knowledge, there are no studies that have investigated food skills in people with diabetes. Nevertheless, targeted interventions to improve the food skills of people living with diabetes are prudent given that food is central to managing glycemic control. People with type 1 diabetes may be taught how to match insulin to carbohydrate quantity and quality [Grade C, Level 2 ] or they may maintain consistency in carbohydrate quantity and quality [Grade D, Consensus]. From: Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med 6 6 : e pmed For more information, visit www. Chan reports grants from Danone Institute, Canadian Foundation for Dietetic Research, Alberta Livestock and Meat Agency, Dairy Farmers of Canada, Alberta Pulse Growers, and Western Canada Grain Growers, outside the submitted work; in addition, Dr. Chan has a patent No. Catherine Freeze reports personal fees from Dietitians of Canada and Government of Prince Edward Island, outside the submitted work. No other authors have anything to disclose. All content on guidelines. ca, CPG Apps and in our online store remains exactly the same. For questions, contact communications diabetes. Become a Member Order Resources Home About Contact DONATE. Next Previous. Key Messages Recommendations Figures Full Text References. Chapter Headings Introduction Ethnocultural Diversity Approach to Nutrition Therapy Energy Macronutrients Intensive Lifestyle Intervention Dietary Patterns Diets Emphasizing Specific Foods Special Considerations for People with Type 1 Diabetes and Type 2 Diabetes on Insulin Other Considerations Other Relevant Guidelines Author Disclosures. Key Messages People with diabetes should receive nutrition counselling by a registered dietitian. Nutrition therapy can reduce glycated hemoglobin A1C by 1. Reduced caloric intake to achieve and maintain a healthier body weight should be a treatment goal for people with diabetes with overweight or obesity. The macronutrient distribution is flexible within recommended ranges and will depend on individual treatment goals and preferences. Replacing high-glycemic-index carbohydrates with low-glycemic-index carbohydrates in mixed meals has a clinically significant benefit for glycemic control in people with type 1 and type 2 diabetes. Consistency in spacing and intake of carbohydrate intake and in spacing and regularity in meal consumption may help control blood glucose and weight. Intensive healthy behaviour interventions in people with type 2 diabetes can produce improvements in weight management, fitness, glycemic control and cardiovascular risk factors. A variety of dietary patterns and specific foods have been shown to be of benefit in people with type 1 and type 2 diabetes. People with diabetes should be encouraged to choose the dietary pattern that best aligns with their values, preferences and treatment goals, allowing them to achieve the greatest adherence over the long term. Key Messages for People with Diabetes It is natural to have questions about what food to eat. A registered dietitian can help you develop a personalized meal plan that considers your culture and nutritional preferences to help you achieve your blood glucose and weight management goals. Food is key in the management of diabetes and reducing the risk of heart attack and stroke. Try to prepare more of your meals at home and use fresh unprocessed ingredients. Try to prepare meals and eat together as a family. This is a good way to model healthy food behaviours to children and teenagers, which could help reduce their risk of becoming overweight or developing diabetes. With prediabetes and recently diagnosed type 2 diabetes, weight loss is the most important and effective dietary strategy if you have overweight or obesity. There are many strategies that can help with weight loss. The best strategy is one that you are able to maintain long term. Adoption of diabetes-friendly eating habits can help manage your blood glucose levels as well as reduce your risk for developing heart and blood vessel disease for those with either type 1 or type 2 diabetes. Select whole and less refined foods instead of processed foods, such as sugar-sweetened beverages, fast foods and refined grain products. Pay attention to both carbohydrate quality and quantity. Include low-glycemic-index foods, such as legumes, whole grains, and fruit and vegetables. These foods can help control blood glucose and cholesterol levels. Consider learning how to count carbohydrates as the quantity of carbohydrate eaten at one time is usually important in managing diabetes. Select unsaturated oils and nuts as the preferred dietary fats. Choose lean animal proteins. Select more vegetable protein. The style of eating that works well for diabetes may be described as a Mediterranean style diet, Nordic style diet, DASH diet or vegetarian style diet. All of these diets are rich in protective foods and have been shown to help manage diabetes and cardiovascular disease. They all contain the key elements of a diabetes-friendly diet. Introduction Nutrition therapy and counselling are an integral part of the treatment and self-management of diabetes. Ethnocultural Diversity Canada is a country rich in ethnocultural diversity. Approach to Nutrition Therapy Nutrition therapy should be individualized, regularly evaluated, reinforced in an intensive manner 11,12 , and should incorporate self-management education Figure 1 Nutritional management of hyperglycemia in type 2 diabetes. A1C , glycated hemoglobin. Macronutrients The ideal macronutrient distribution for the management of diabetes may vary, depending on the quality of the various macronutrients, the goals of the dietary treatment regimen and the individual's values and preferences. Carbohydrate CHO broadly include available CHO from starches and sugars and unavailable CHO from fibre. Glycemic Index The glycemic index GI provides an assessment of the quality of CHO-containing foods based on their ability to raise blood glucose BG Dietary fibre Dietary fibre includes the edible components of plant material that are resistant to digestion by human enzymes nonstarch polysaccharides and lignin, as well as associated substances. Sugars Added sugars, especially from fructose-containing sugars high fructose corn syrup [HFCS], sucrose and fructose , have become a focus of intense public health concern. Fat The DRIs do not specify an AI or RDA for total fat, monounsaturated fatty acids MUFA , saturated fatty acids SFA , or dietary cholesterol. Protein The DRIs specify a recommended dietary allowance RDA for protein of 0. Macronutrient substitutions The ideal macronutrient distribution for the management of diabetes can be individualized. Intensive Lifestyle Intervention Intensive lifestyle intervention ILI programs in diabetes usually consist of behavioural interventions combining dietary modification and increased physical activity. Dietary Patterns A variety of dietary patterns have been studied for people with prediabetes and diabetes. Mediterranean dietary patterns A Mediterranean diet primarily refers to a plant-based diet first described in the s Vegetarian dietary patterns Vegetarian dietary patterns include lacto-ovovegetarian, lactovegetarian, ovovegetarian and vegan dietary patterns. DASH and low-sodium dietary patterns Dietary approaches to reducing BP have focused on sodium reduction and the Dietary Approaches to Stop Hypertension DASH dietary pattern. Nordic dietary patterns The Nordic Diet was developed as a Nordic translation of the Mediterranean, Portfolio, DASH and NCEP dietary patterns, using foods typically consumed as part of a traditional Nordic diet in the context of Nordic Nutrition Recommendations Popular weight-loss diets Numerous popular weight-loss diets providing a range of macronutrient profiles are available to people with diabetes. Diets Emphasizing Specific Foods Dietary pulses and legumes Dietary pulses, the dried seeds of nonoil seed legumes, include beans, peas, chickpeas, and lentils. Fruit and vegetables Eating Well with Canada's Food Guide recommends up to 7 to 10 servings of fruit and vegetables per day Nuts Nuts include both peanuts a legume and tree nuts, such as almonds, walnuts, pistachios, pecans, Brazil nuts, cashews, hazelnuts, macadamia nuts and pine nuts. Whole grains Health Canada defines whole grains as those that contain all 3 parts of the grain kernel bran, endosperm, germ in the same relative proportions as they exist in the intact kernel. Dairy products Dairy products broadly include low- and full-fat milk, cheese, yogurt, other fermented products and ice cream. Special Considerations for People with Type 1 Diabetes and Type 2 Diabetes on Insulin For persons on insulin, consistency in CHO intake and spacing and regularity in meal consumption may help control BG levels — Other Considerations Non-nutritive sweeteners Sugar substitutes, which include high-intensity sweeteners and sugar alcohols, are regulated as food additives in Canada. Meal replacements Weight loss programs for people with diabetes may use partial meal replacement plans. Alcohol The same precautions regarding alcohol consumption in the general population apply to people with diabetes Vitamin and mineral supplements People with diabetes should be encouraged to meet their nutritional needs by consuming a well-balanced diet by following Eating Well with Canada's Food Guide Fasting and diabetes Within the lay literature, intermittent energy restriction strategies for weight loss have become more prevalent. Ramadan Traditionally, Muslims with type 1 and insulin-requiring type 2 diabetes have been exempted from participation in Ramadan fasting, due to concerns of hypo- and hyperglycemia. Food skills While there is no universally agreed upon definition of food skills, it is generally thought that they are interdependent technical, mechanical, conceptual and perceptual skills that are necessary to safely select and plan, prepare, and store nutritious and culturally-acceptable meals and snacks — Recommendations People with diabetes should receive nutrition counselling by a registered dietitian to lower A1C levels [Grade B, Level 2 3 , for those with type 2 diabetes; Grade D, Consensus, for type 1 diabetes] and to reduce hospitalization rates [Grade C, Level 3 8 ]. Nutrition education may be delivered in either a small group or one-on-one setting [Grade B, Level 2 18 ]. Group education should incorporate adult education principles, such as hands-on activities, problem solving, role playing and group discussions [Grade B, Level 2 19 ]. Individuals with diabetes should be encouraged to follow Eating Well with Canada's Food Guide in order to meet their nutritional needs [Grade D, Consensus]. In people with overweight or obesity with diabetes, a nutritionally balanced, calorie-reduced diet should be followed to achieve and maintain a lower, healthier body weight [Grade A, Level 1A 29,30 ]. An intensive healthy behaviour intervention program, combining dietary modification and increased physical activity, may be used to achieve weight loss, improve glycemic control and reduce CV risk [Grade A, Level 1A 30 ]. People with type 2 diabetes should maintain regularity in timing and spacing of meals to optimize glycemic control [Grade D, Level 4 ]. Adults with diabetes should select carbohydrate food sources with a low-GI to help optimize glycemic control [Grade B, Level 2 46,47 for type 1 diabetes; Grade B, Level 2 32,44 for type 2 diabetes], to improve LDL-C [Grade C, Level 3 49 ] and to decrease CV risk [Grade D, Level 4 52 ]. The following dietary patterns may be considered in people with type 2 diabetes, incorporating patient preferences, including: Mediterranean-style dietary pattern to reduce major CV events [Grade A, Level 1A ] and improve glycemic control [Grade B, Level 2 50, ]. Vegan or vegetarian dietary pattern to improve glycemic control [Grade B, Level 2 , ], body weight [Grade C, Level 3 ], and blood lipids, including LDL-C [Grade B, Level 2 ] and reduce myocardial infarction risk [Grade B, Level 2 ]. DASH dietary pattern to improve glycemic control [Grade C, Level 2 ], BP [Grade D, Level 4 — ], and LDL-C [Grade B, Level 2 , ] and reduce major CV events [Grade B, Level 3 ]. Dietary patterns emphasizing dietary pulses e. beans, peas, chickpeas, lentils to improve glycemic control [Grade B, Level 2 ], systolic BP [Grade C, Level 2 ] and body weight [Grade B, Level 2 ]. Dietary patterns emphasizing fruit and vegetables to improve glycemic control [Grade B, Level 2 , ] and reduce CV mortality [Grade C, Level 3 79 ]. Dietary patterns emphasizing nuts to improve glycemic control [Grade B, Level 2 ], and LDL-C [Grade B, Level 2 ]. Other Relevant Guidelines Chapter 7. Self-Management Education and Support Chapter Physical Activity and Diabetes Chapter Weight Management in Diabetes Chapter Complementary and Alternative Medicine for Diabetes Chapter Dyslipidemia Chapter Treatment of Hypertension Chapter Type 1 Diabetes in Children and Adolescents Chapter Type 2 Diabetes in Children and Adolescents Chapter Diabetes and Pregnancy Chapter Diabetes in Older People Chapter Type 2 Diabetes and Indigenous Peoples. 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Rickheim PL,Weaver TW, Flader JL, et al. Assessment of group versus individual diabetes education: A randomized study. TrentoM, Basile M, Borgo E, et al. A randomised controlled clinical trial of nurse-, dietitian- and pedagogist-led group care for the management of type 2 diabetes. J Endocrinol Invest ;— Pérez-Escamilla R, Hromi-Fiedler A, Vega-López S, et al. Impact of peer nutrition education on dietary behaviors and health outcomes among Latinos: A systematic literature review. J Nutr Educ Behav ;— Ralston JD, Hirsch IB, Hoath J, et al. Web-based collaborative care for type 2 diabetes: A pilot randomized trial. Marcy TR, Britton ML, Harrison D. Identification of barriers to appropriate dietary behavior in low-income patients with type 2 diabetes mellitus. Diabetes Ther ;— Christensen NK, Terry RD, Wyatt S, et al. Quantitative assessment of dietary adherence in patients with insulin-dependent diabetes mellitus. Toeller M, Klischan A, Heitkamp G, et al. Nutritional intake of IDDM patients from 30 centres in Europe. EURODIAB IDDM Complications Study Group. Diabetologia ;— Glazier RH, Bajcar J, Kennie NR, et al. A systematic review of interventions to improve diabetes care in socially disadvantaged populations. Anderson TJ, Grégoire J, Pearson GJ, et al. Can J Cardiol ;— Wing RR. Weight loss in the management of type 2 diabetes. In: Gerstein HC, Haynes B, eds. Evidence-based diabetes. Ontario: B. C, Decker Inc. Tuomilehto J, Lindström J, Eriksson JG, et al. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Engl J Med ;— KnowlerWC, Barrett-Connor E, Fowler SE, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. The Look Ahead Research Group, Wing RR. Long term effects of a lifestyle intervention on weight and cardiovascular risk factors in individuals with type 2 diabetes: Four year results of the Look AHEAD trial. Arch Intern Med ;— Food and Nutrition Board, Institute of Medicine of the National Academics. Dietary reference intakes for energy, carbohydrate, fiber, fat, fatty acids, cholesterol, protein and amino acids. Washington: The National Academies Press, Barnard ND, Cohen J, Jenkins DJ, et al. A low-fat vegan diet improves glycemic control and cardiovascular risk factors in a randomized clinical trial in individuals with type 2 diabetes. Kirk JK, Graves DE, Craven TE, et al. Restricted-carbohydrate diets in patients with type 2 diabetes: A meta-analysis. Dyson P. Low carbohydrate diets and type 2 diabetes: What is the latest evidence? van Wyk HJ, Davis RE, Davies JS. A critical review of low-carbohydrate diets in people with type 2 diabetes. Diabet Med ;— Johnston BC, Kanters S, Bandayrel K, et al. Comparison of weight loss among named diet programs in overweight and obese adults: A meta-analysis. JAMA ;— Yabe D, Iwasaki M, Kuwata H, et al. Sodium-glucose co-transporter-2 inhibitor use and dietary carbohydrate intake in Japanese individuals with type 2 diabetes: A randomized, open-label, 3-arm parallel comparative, exploratory study. Diabetes Obes Metab ;— Krebs JD, Parry Strong A, Cresswell P, et al. A randomised trial of the feasibility of a low carbohydrate diet vs standard carbohydrate counting in adults with type 1 diabetes taking body weight into account. Asia Pac J Clin Nutr ;— Nielsen JV, Gando C, Joensson E, et al. Low carbohydrate diet in type 1 diabetes, long-term improvement and adherence: A clinical audit. Diabetol Metab Syndr ; Ranjan A, Schmidt S, Damm-Frydenberg C, et al. Low-carbohydrate diet impairs the effect of glucagon in the treatment of insulin-induced mild hypoglycemia: A randomized crossover study. Diabetes Care ;—5. Ranjan A, Schmidt S, Madsbad S, et al. Finding similar items Consensus Study Report. Dietary Reference Intakes The Essential Guide to Nutrient Requirements Download Free PDF. Read Free Online. For each nutrient of food component, information includes: Estimated average requirement and its standard deviation by age and gender. Recommended dietary allowance, based on the estimated average requirement and deviation. Adequate intake level, where a recommended dietary allowance cannot be based on an estimated average requirement. Tolerable upper intake levels above which risk of toxicity would increase. Along with dietary reference values for the intakes of nutrients by Americans and Canadians, this book presents recommendations for health maintenance and the reduction of chronic disease risk. In addition, Dietary Reference Intakes: The Essential Reference for Dietary Planning and Assessment provides information about: Guiding principles for nutrition labeling and fortification Applications in dietary planning Proposed definition of dietary fiber A risk assessment model for establishing upper intake levels for nutrients Proposed definition and plan for review of dietary antioxidants and related compounds Dietitians, community nutritionists, nutrition educators, nutritionists working in government agencies, and nutrition students at the postsecondary level, as well as other health professionals, will find Dietary Reference Intakes: The Essential Reference for Dietary Planning and Assessment an invaluable resource. Contributor s : Institute of Medicine ; Jennifer J. Otten, Jennifer Pitzi Hellwig, and Linda D. Meyers, Editors. Additional Book Information Topics Food and Nutrition — Nutrition - Dietary Reference Intakes. Suggested Citation Institute of Medicine. Dietary Reference Intakes: The Essential Guide to Nutrient Requirements. Washington, DC: The National Academies Press. What is skim? Links Infographic: Dietary Reference Intakes. Copyright Information The National Academies Press NAP has partnered with Copyright Clearance Center's Marketplace service to offer you a variety of options for reusing NAP content. com marketplace. Loading stats for Dietary Reference Intakes: The Essential Guide to Nutrient Requirements What is an eBook? Why is an eBook better than a PDF? Where do I get eBook files? Front Matter. Introduction to the Dietary Reference Intakes. Applying the Dietary Reference Intakes. Macronutrients, Healthful Diets, and Physical Activity. In response to EAA ingestion and independent of leucine content, MPS rates and several signaling proteins related to muscle hypertrophy i. were significantly increased. While more research certainly needs to be conducted to better identify the potential impact and role of protein intake before endurance exercise, the priority for an endurance athlete in the hours leading up to competition should be focused on appropriate carbohydrate intake to fully maximize endogenous production of glycogen. As with endurance exercise, the majority of studies that have employed some form of protein or amino acid ingestion before bouts of resistance exercise have done so in conjunction with an identical dose during the post-exercise period as well. For example, Tipton and colleagues [ ] used an acute resistance exercise and feeding model to report that MPS rates were similar when a g dose of whey protein was ingested immediately before or immediately after a bout of lower body resistance training. Andersen et al. In this study, participants were randomized to ingest either 25 g of a protein blend In the group that consumed the protein-amino acid blend, type I and type II muscle fibers experienced a significant increase in size. Also, the protein-amino acid group experienced a significant increase in squat jump height while no changes occurred in the carbohydrate group. Using a similar study design, Hoffman and colleagues [ ] had collegiate football players who had been regularly performing resistance-training ingest 42 g of hydrolyzed collagen protein either immediately before and immediately after exercise, or in the morning and evening over the course of ten weeks of resistance training. In this study, the timing of protein intake did not impact changes in strength, power and body composition experienced from the resistance-training program. When examining the discrepant findings, one must consider a few things. First, the protein source in the Hoffman et al. study was mostly a collagen hydrolysate i. Finally, the study participants in the Andersen et al. More recently, Schoenfeld and colleagues [ ] published the first longitudinal study to directly compare the effects of ingesting 25 g of whey protein isolate either immediately before or immediately after each workout. This study is significant as it is the first investigation to attempt to compare pre versus post-workout ingestion of protein. The authors raised the question that the size, composition, and timing of a pre-exercise meal may impact the extent to which adaptations are seen in these studies. However, a key limitation of this investigation is the very limited training volumes these subjects performed. The total training sessions over the week treatment period was 30 sessions i. One would speculate that the individuals who would most likely benefit from peri-workout nutrition are those who train at much higher volumes. For instance, American collegiate athletes per NCAA regulations NCAA Bylaw 2. Thus, the average college athlete trains more in two weeks than most subjects train during an entire treatment period in studies in this category. In one of the only studies to use older participants, Candow and colleagues [ 15 ] assigned 38 men between the ages of 59—76 years to ingest a 0. While protein administration did favorably improve resistance-training adaptations, the timing of protein before or after workouts did not invoke any differential change. An important point to consider with the results of this study is the sub-optimal dose of protein approximately 26 g of whey protein versus the known anabolic resistance that has been demonstrated in the skeletal muscle of elderly individuals [ ]. In this respect, the anabolic stimulus from a g dose of whey protein may not have sufficiently stimulated muscle protein synthesis or have been of appropriate magnitude to induce differences between conditions. Clearly, more research is needed to determine if a greater dose of protein delivered before or after a workout may exert an impact on adaptations seen during resistance training in an elderly population. Limited studies are available that have examined the effect of providing protein throughout an acute bout of resistance exercise, particularly studies designed to explicitly determine if protein administration during exercise was more favorable than other times of administration. However, when examined over the course of 12 weeks, the increases in fiber size seen after ingesting a solution containing 6 g of EAA alone was less than when it was combined with carbohydrate [ 96 ]. The post-exercise time period has been aggressively studied for its ability to heighten various training outcomes. While a large number of acute exercise and nutrient administration studies have provided multiple mechanistic explanations for why post-exercise feeding may be advantageous [ , , , , ], other studies suggest this study model may not be directly reflective of adaptations seen over the course of several weeks or months [ ]. As highlighted throughout the pre-exercise protein timing section, the majority of studies that have examined some aspect of post-exercise protein timing have done so while also administering an identical dose of protein immediately before each workout [ 16 , , , ]. These results, however, are not universal as Hoffman et al. Of note, participants in the Hoffman study were all highly-trained collegiate athletes who reported consuming a hypoenergetic diet. Candow et al. As mentioned previously, it is possible that the dose of protein may not have been an appropriate amount to properly stimulate anabolism. In this respect, a small number of studies have examined the impact of solely ingesting protein after exercise. As discussed earlier, Tipton and colleagues [ ] used an acute model to determine changes in MPS rates when a g bolus of whey protein was ingested immediately before or immediately after a single bout of lower-body resistance training. MPS rates were significantly, and similarly, increased under both conditions. Until recently, the only study that examined the effects of post-exercise protein timing in a longitudinal manner was the work of Esmarck et al. In this study, 13 elderly men average age of 74 years consumed a small combination of carbohydrates 7 g , protein 10 g and fat 3 g either immediately within 30 min or 2 h after each bout of resistance exercise done three times per week for 12 weeks. Changes in strength and muscle size were measured, and it was concluded that ingesting nutrients immediately after each workout led to greater improvements in strength and muscle cross-sectional area than when the same nutrients were ingested 2 h later. While interesting, the inability of the group that delayed supplementation but still completed the resistance training program to experience any measurable increase in muscle cross-sectional area has led some to question the outcomes resulting from this study [ 5 , ]. Further and as discussed previously with the results of Candow et al. Schoenfeld and colleagues [ ] published results that directly examined the impact of ingesting 25 g of whey protein immediately before or immediately after bouts of resistance-training. All study participants trained three times each week targeting all major muscle groups over a week period, and the authors concluded no differences in strength and hypertrophy were seen between the two protein ingestion groups. These findings lend support to the hypothesis that ingestion of whey protein immediately before or immediately after workouts can promote improvements in strength and hypertrophy, but the time upon which nutrients are ingested does not necessarily trump other feeding strategies. Reviews by Aragon and Schoenfeld [ ] and Schoenfeld et al. The authors suggested that when recommended levels of protein are consumed, the effect of timing appears to be, at best, minimal. Indeed, research shows that muscles remain sensitized to protein ingestion for at least 24 h following a resistance training bout [ ] leading the authors to suggest that the timing, size and composition of any feeding episode before a workout may exert some level of impact on the resulting adaptations. In addition to these considerations, recent work by MacNaughton and colleagues [ ] reported that the acute ingestion of a g dose versus g of whey protein resulted in significantly greater increases in MPS in young subjects who completed an intense, high volume bout of resistance exercise that targeted all major muscle groups. Notwithstanding these conclusions, the number of studies that have truly examined a timing question is rather scant. Moreover, recommendations must capture the needs of a wide range of individuals, and to this point, a very small number of studies have examined the impact of nutrient timing using highly trained athletes. From a practical standpoint, some athletes may struggle, particularly those with high body masses, to consume enough protein to meet their required daily needs. As a starting point, it is important to highlight that most of the available research on this topic has largely used non-athletic, untrained populations except two recent publications using trained men and women [ , ]. Whether or not these findings apply to highly trained, athletic populations remains to be seen. Changes in weight loss and body composition were compared, and slightly greater weight loss occurred when the majority of calories was consumed in the morning. As a caveat to what is seemingly greater weight loss when more calories are shifted to the morning meals, higher amounts of fat-free mass were lost as well, leading to questions surrounding the long-term efficacy of this strategy regarding weight management and metabolic activity. Notably, this last point speaks to the importance of evenly spreading out calories across the day and avoiding extended periods of time where no food, protein in particular, is consumed. A large observational study [ ] examined the food intake of free-living individuals males and females ,and a follow-up study from the same study cohort [ ] reported that the timing of food consumption earlier vs. later in the day was correlated to the total daily caloric intake. Wu and colleagues [ ] reported that meals later in the day lead to increased rates of lipogenesis and adipose tissue accumulation in an animal model and, while limited, human research has also provided support. Previously it has been shown that people who skip breakfast display a delayed activation of lipolysis along with an increase in adipose tissue production [ , ]. More recently, Jakubowicz and colleagues [ ] had overweight and obese women consume cal each day for a week period. Approximately 2. While these results provide insight into how calories could be more optimally distributed throughout the day, a key perspective is that these studies were performed in sedentary populations without any form of exercise intervention. Thus, their relevance to athletes or highly active populations might be limited. Furthermore, the current research approach has failed to explore the influence of more evenly distributed meal patterns throughout the day. Meal frequency is commonly defined as the number of feeding episodes that take place each day. For years, recommendations have indicated that increasing meal frequency may serve as an effective way to influence weight loss, weight maintenance, and body composition. These assertions were based upon the epidemiological work of Fabry and colleagues [ , ] who reported that mean skinfold thickness was inversely related to the frequency of meals. One of these studies involved overweight individuals between 60 and 64 years of age while the other investigation involved 80 participants between the ages of 30—50 years of age. An even larger study published by Metzner and colleagues [ ] reported that in a sample of men and women between 35 and 60 years of age, meal frequency and adiposity were inversely related. While intriguing, the observational nature of these studies does not agree with more controlled experiments. For example, a study by Farshchi et al. The irregular meal pattern was found to result in increased levels of appetite, and hunger leading one to question if the energy provided in each meal was inadequate or if the energy content of each meal could have been better matched to limit these feelings while still promoting weight loss. Furthermore, Cameron and investigators [ ] published what is one of the first studies to directly compare a greater meal frequency to a lower frequency. In this study, 16 obese men and women reduced their energy intake by kcals per day and were assigned to one of two isocaloric groups: one group was instructed to consume six meals per day three traditional meals and three snacks , while the other group was instructed to consume three meals per day for an eight-week period. Changes in body mass, obesity indices, appetite, and ghrelin were measured at the end of the eight-week study, and no significant differences in any of the measured endpoints were found between conditions. These results also align with more recent results by Alencar [ ] who compared the impact of consuming isocaloric diets consisting of two meals per day or six meals per day for 14 days in overweight women on weight loss, body composition, serum hormones ghrelin, insulin , and metabolic glucose markers. No differences between groups in any of the measured outcomes were observed. A review by Kulovitz et al. Similar conclusions were drawn in a meta-analysis by Schoenfeld and colleagues [ ] that examined the impact of meal frequency on weight loss and body composition. Although initial results suggested a potential advantage for higher meal frequencies on body composition, sub-analysis indicated that findings were confounded by a single study, casting doubt as to whether the strategy confers any beneficial effects. From this, one might conclude that greater meal frequency may, indeed, favorably influence weight loss and body composition changes if used in combination with an exercise program for a short period of time. Certainly, more research is needed in this area, particularly studies that manipulate meal frequency in combination with an exercise program in non-athletic as well as athletic populations. Finally, other endpoints related to meal frequency i. may be of interest to different populations, but they extend beyond the scope of this position stand. An extension of altering the patterns or frequency of when meals are consumed is to examine the pattern upon which protein feedings occur. Moore and colleagues [ ] examined the differences in protein turnover and synthesis rates when participants ingested different patterns, in a randomized order, of an g total dose of protein over a h measurement period following a bout of lower body resistance exercise. One of the protein feeding patterns required participants to consume two g doses of whey protein isolate approximately 6 h apart. Another condition required the consumption of four, g doses of whey protein isolate every 3 h. The final condition required the participants to consume eight, g doses of whey protein isolate every 90 min. Rates of muscle protein turnover, synthesis, and breakdown were compared, and the authors concluded that protein turnover and synthesis rates were greatest when intermediate-sized g doses of whey protein isolate were consumed every 3 h. One of the caveats of this investigation was the very low total dose of protein consumed. Eighty grams of protein over a h period would be grossly inadequate for athletes performing high volumes of training as well as those who are extremely heavy e. A follow-up study one year later from the same research group determined myofibrillar protein synthesis rates after randomizing participants into three different protein ingestion patterns and examined how altering the pattern of protein administration affected protein synthesis rates after a bout of resistance exercise [ ]. Two key outcomes were identified. First, rates of myofibrillar protein synthesis rates increased in all three groups. Second, when four, g doses of whey protein isolate were consumed every 3 h over a h post-exercise period, significantly greater in comparison to the other two patterns of protein ingestion rates of myofibrillar protein synthesis occurred. In combining the results of both studies, one can conclude that ingestion of intermediate protein doses 20 g consumed every 3 h creates more favorable changes in both whole-body as well as myofibrillar protein synthesis [ , ]. Although both studies employed short-term methodology and other patterns or doses have yet to be examined, the results thus far consistently suggest that the timing or pattern in which high-quality protein is ingested may favorably impact net protein balance as well as rates of myofibrillar protein synthesis. An important caveat to these findings is that supplementation in most cases was provided in exclusion of other macronutrients over the duration of the study. Consumption of mixed meals delays gastric emptying and thus may result in different metabolic effects. Moreover, the fact that whey is a fast-absorbing protein source [ ] further confounds the ability to generalize results to traditional mixed-meal diets, as the potential for oxidation is increased with larger dosages, particularly in the absence of other macronutrients. Whether acute MPS responses translate to longitudinal changes in hypertrophy or fiber composition also remains to be determined [ ]. Protein pacing involves the consumption of 20—40 g servings of high-quality protein, from both whole food and protein supplementation, evenly spaced throughout the day, approximately every 3 h. The first meal is consumed within 60 min of waking in the morning, and the last meal is eaten within 3 h of going to sleep at night. Arciero and colleagues [ , ] have most recently demonstrated increased muscular strength and power in exercise-trained physically fit men and women using protein pacing compared to ingestion of similar sized meals at similar times but different protein contents, both of which included the same multi-component exercise training during a week intervention. In support of this theory one can point to the well characterized changes seen in peak MPS rates within 90 min after oral ingestion of protein [ ] and the return of MPS rates to baseline levels in approximately 90 min despite elevations in serum amino acid levels [ ]. Thus if efficacious protein feedings are placed too close together it remains possible that the ability of skeletal muscle anabolism to be fully activated might be limited. While no clear consensus exists as to the acceptance of this theory, conflicting findings exist between longitudinal studies that did provide protein feedings in close proximity to each other [ 16 , , ], making this an area that requires more investigation. Finally, while the mechanistic implications of pulsed vs. bolus protein feedings and their effect on MPS rates may help ultimately guide application, the practical importance has yet to be demonstrated. Eating before sleep has long been controversial [ , , ]. However, methodological considerations in the original studies such as the population used, time of feeding, and size of the pre-sleep meal confounds any conclusions that can be drawn. Recent work using protein-centric beverages consumed min before sleep and 2 h after the last meal dinner have identified pre-sleep protein consumption as advantageous to MPS, muscle recovery, and overall metabolism in both acute and long-term studies [ , ]. For example, data indicate that 30—40 g of casein protein ingested min prior to sleep [ ] or via nasogastric tubing [ ] increased overnight MPS in both young and old men, respectively. Likewise, in an acute setting, 30 g of whey protein, 30 g of casein protein, and 33 g of carbohydrate consumption min pre-sleep resulted in elevated morning resting metabolic rate in fit young men compared to a non-caloric placebo [ ]. Of particular interest is that Madzima et al. This infers that casein protein consumed pre-sleep maintains overnight lipolysis and fat oxidation. This finding was verifiedwhen Kinsey et al. It was concluded that pre-sleep casein did not blunt overnight lipolysis or fat oxidation. Similar to Madzima et al. Of note, it appears that previous exercise training completely ameliorates any rise in insulin when eating at night before sleep [ ] and the combination of pre-sleep protein and exercise has been shown to reduce blood pressure and arterial stiffness in young obese women with prehypertension and hypertension [ ]. To date, only two studies involving nighttime protein have been carried out for longer than four weeks. Snijders et al. The group receiving the protein-centric supplement each night before sleep had greater improvements in muscle mass and strength over the weeks. Of note, this study was non-nitrogen balanced and the protein group received approximately 1. More recently, in a nitrogen-balanced design using young healthy men and women, Antonio et al. All subjects maintained their usual exercise program. The authors reported no differences in body composition or performance between the morning and evening casein supplementation groups. A potential explanation for the lack of findings might stem from the already high intake of protein by the study participants before the study commenced. However, it is worth noting that although not statistically significant, the morning group added 0. Thus, it appears that protein consumption in the evening before sleep represents another opportunity to consume protein and other nutrients. Certainly more research is needed to determine if timing per se, or the mere addition of total daily protein can affect body composition or recovery via nighttime feeding. Nutrient timing is an area of research that continues to gather interest from researchers, coaches, and consumers. In reviewing the literature, two key considerations should be made. First, all findings surrounding nutrient timing require appropriate context because factors such as age, sex, fitness level, previous fueling status, dietary status, training volume, training intensity, program design, and time before the next training bout or competition can influence the extent to which timing may play a role in the adaptive response to exercise. Second, nearly all research within this topic requires further investigation. The reader must keep in perspective that in its simplest form nutrient timing is a feeding strategy that in nearly all situations may be helpful towards the promotion of recovery and adaptations towards training. This context is important because many nutrient timing studies demonstrate favorable changes that do not meet statistical thresholds of significance thereby leaving the reader to interpret the level of practical significance that exists from the findings. It is noteworthy that differences in real-world athletic performances can be so small that even strategies that offer a modicum of benefit are still worth pursuing. In nearly all such situations, this approach results in an athlete receiving a combination of nutrients at specific times that may be helpful and has not yet shown to be harmful. This perspective also has the added advantage of offering more flexibility to the fueling considerations a coach or athlete may employ. Using this approach, when both situations timed or non-timed ingestion of nutrients offer positive outcomes then our perspective is to advise an athlete to follow whatever strategy offers the most convenience or compliance if for no other reason than to deliver vital nutrients in amounts at a time that will support the physiological response to exercise. Finally, it is advisable to remind the reader that due to the complexity, cost and invasiveness required to answer some of these fundamental questions, research studies often employ small numbers of study participants. Also, for the most part studies have primarily evaluated men. This latter point is particularly important as researchers have documented that females oxidize more fat when compared to men, and also seem to utilize endogenous fuel sources to different degrees [ 28 , 29 , 30 ]. Furthermore, the size of potential effects tends to be small, and when small potential effects are combined with small numbers of study participants, the ability to determine statistical significance remains low. Nonetheless, this consideration remains relevant because it underscores the need for more research to better understand the possibility of the group and individual changes that can be expected when the timing of nutrients is manipulated. In many situations, the efficacy of nutrient timing is inherently tied to the concept of optimal fueling. Thus, the importance of adequate energy, carbohydrate, and protein intake must be emphasized to ensure athletes are properly fueled for optimal performance as well as to maximize potential adaptations to exercise training. High-intensity exercise particularly in hot and humid conditions demands aggressive carbohydrate and fluid replacement. Consumption of 1. The need for carbohydrate replacement increases in importance as training and competition extend beyond 70 min of activity and the need for carbohydrate during shorter durations is less established. Adding protein 0. Moreover, the additional protein may minimize muscle damage, promote favorable hormone balance and accelerate recovery from intense exercise. For athletes completing high volumes i. The use of a 20—g dose of a high-quality protein source that contains approximately 10—12 g of the EAA maximizes MPS rates that remain elevated for three to four hours following exercise. Protein consumption during the peri-workout period is a pragmatic and sensible strategy for athletes, particularly those who perform high volumes of exercise. Not consuming protein post-workout e. The impact of delivering a dose of protein with or without carbohydrates during the peri-workout period over the course of several weeks may operate as a strategy to heighten adaptations to exercise. Like carbohydrate, timing related considerations for protein appear to be of lower priority than the ingestion of optimal amounts of daily protein 1. In the face of restricting caloric intake for weight loss, altering meal frequency has shown limited effects on body composition. However, more frequent meals may be more beneficial when accompanied by an exercise program. The impact of altering meal frequency in combination with an exercise program in non-athlete or athlete populations warrants further investigation. It is established that altering meal frequency outside of an exercise program may help with controlling hunger, appetite and satiety. Nutrient timing strategies that involve changing the distribution of intermediate-sized protein doses 20—40 g or 0. One must also consider that other factors such as the type of exercise stimulus, training status, and consumption of mixed macronutrient meals versus sole protein feedings can all impact how protein is metabolized across the day. When consumed within 30 min before sleep, 30—40 g of casein may increase MPS rates and improve strength and muscle hypertrophy. In addition, protein ingestion prior to sleep may increase morning metabolic rate while exerting minimal influence over lipolysis rates. 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| Selection of Optimal Feeding Formula - ART MEDICAL | Cermak NM, Res PT, De Groot LC, Saris WH, Van Loon LJ. Canadian Diabetes AssociationNationalNutrition Committee technical review: Nonnutritive intense sweeteners in diabetes management. Alcohol The same precautions regarding alcohol consumption in the general population apply to people with diabetes Long-term metformin use and vitamin B12 deficiency in the Diabetes Prevention Program Outcomes Study. Effect of chromium supplementation on glucose metabolism and lipids: a systematic review of randomized controlled trials. Whereas no single eating pattern has emerged as being clearly superior to all others for all diabetes-related outcomes, evidence suggests certain eating patterns are better for specific outcomes. Protein promotes feelings of fullness, spares muscle loss and has the highest thermic effect, meaning it takes more calories to digest compared to carbs or fats 14 , 15 , |
| Plant-Soil Interactions: Nutrient Uptake | However, when these nitrogen sources are not available, certain species of plants from the family Fabaceae legumes initiate symbiotic relationships with a group of nitrogen fixing bacteria called Rhizobia. Copyright Information The National Academies Press NAP has partnered with Copyright Clearance Center's Marketplace service to offer you a variety of options for reusing NAP content. For instance, research related to caffeine [ 13 ], creatine [ 14 , 15 , 16 ] and bicarbonate [ 17 ] have indicated that timing may affect the acute and chronic response to exercise. Arch Intern Med ;— Article PubMed Google Scholar Coyle EF, Coggan AR, Hemmert MK, Ivy JL. Optimizing the combination insulin bolus split for a high-fat, high-protein meal in children and adolescents using insulin pump therapy. |
Optimal nutrient distribution -
Select unsaturated oils and nuts as the preferred dietary fats. Choose lean animal proteins. Select more vegetable protein. The style of eating that works well for diabetes may be described as a Mediterranean style diet, Nordic style diet, DASH diet or vegetarian style diet. All of these diets are rich in protective foods and have been shown to help manage diabetes and cardiovascular disease.
They all contain the key elements of a diabetes-friendly diet. Introduction Nutrition therapy and counselling are an integral part of the treatment and self-management of diabetes.
Ethnocultural Diversity Canada is a country rich in ethnocultural diversity. Approach to Nutrition Therapy Nutrition therapy should be individualized, regularly evaluated, reinforced in an intensive manner 11,12 , and should incorporate self-management education Figure 1 Nutritional management of hyperglycemia in type 2 diabetes.
A1C , glycated hemoglobin. Macronutrients The ideal macronutrient distribution for the management of diabetes may vary, depending on the quality of the various macronutrients, the goals of the dietary treatment regimen and the individual's values and preferences.
Carbohydrate CHO broadly include available CHO from starches and sugars and unavailable CHO from fibre. Glycemic Index The glycemic index GI provides an assessment of the quality of CHO-containing foods based on their ability to raise blood glucose BG Dietary fibre Dietary fibre includes the edible components of plant material that are resistant to digestion by human enzymes nonstarch polysaccharides and lignin, as well as associated substances.
Sugars Added sugars, especially from fructose-containing sugars high fructose corn syrup [HFCS], sucrose and fructose , have become a focus of intense public health concern. Fat The DRIs do not specify an AI or RDA for total fat, monounsaturated fatty acids MUFA , saturated fatty acids SFA , or dietary cholesterol.
Protein The DRIs specify a recommended dietary allowance RDA for protein of 0. Macronutrient substitutions The ideal macronutrient distribution for the management of diabetes can be individualized. Intensive Lifestyle Intervention Intensive lifestyle intervention ILI programs in diabetes usually consist of behavioural interventions combining dietary modification and increased physical activity.
Dietary Patterns A variety of dietary patterns have been studied for people with prediabetes and diabetes. Mediterranean dietary patterns A Mediterranean diet primarily refers to a plant-based diet first described in the s Vegetarian dietary patterns Vegetarian dietary patterns include lacto-ovovegetarian, lactovegetarian, ovovegetarian and vegan dietary patterns.
DASH and low-sodium dietary patterns Dietary approaches to reducing BP have focused on sodium reduction and the Dietary Approaches to Stop Hypertension DASH dietary pattern. Nordic dietary patterns The Nordic Diet was developed as a Nordic translation of the Mediterranean, Portfolio, DASH and NCEP dietary patterns, using foods typically consumed as part of a traditional Nordic diet in the context of Nordic Nutrition Recommendations Popular weight-loss diets Numerous popular weight-loss diets providing a range of macronutrient profiles are available to people with diabetes.
Diets Emphasizing Specific Foods Dietary pulses and legumes Dietary pulses, the dried seeds of nonoil seed legumes, include beans, peas, chickpeas, and lentils.
Fruit and vegetables Eating Well with Canada's Food Guide recommends up to 7 to 10 servings of fruit and vegetables per day Nuts Nuts include both peanuts a legume and tree nuts, such as almonds, walnuts, pistachios, pecans, Brazil nuts, cashews, hazelnuts, macadamia nuts and pine nuts.
Whole grains Health Canada defines whole grains as those that contain all 3 parts of the grain kernel bran, endosperm, germ in the same relative proportions as they exist in the intact kernel.
Dairy products Dairy products broadly include low- and full-fat milk, cheese, yogurt, other fermented products and ice cream. Special Considerations for People with Type 1 Diabetes and Type 2 Diabetes on Insulin For persons on insulin, consistency in CHO intake and spacing and regularity in meal consumption may help control BG levels — Other Considerations Non-nutritive sweeteners Sugar substitutes, which include high-intensity sweeteners and sugar alcohols, are regulated as food additives in Canada.
Meal replacements Weight loss programs for people with diabetes may use partial meal replacement plans. Alcohol The same precautions regarding alcohol consumption in the general population apply to people with diabetes Vitamin and mineral supplements People with diabetes should be encouraged to meet their nutritional needs by consuming a well-balanced diet by following Eating Well with Canada's Food Guide Fasting and diabetes Within the lay literature, intermittent energy restriction strategies for weight loss have become more prevalent.
Ramadan Traditionally, Muslims with type 1 and insulin-requiring type 2 diabetes have been exempted from participation in Ramadan fasting, due to concerns of hypo- and hyperglycemia. Food skills While there is no universally agreed upon definition of food skills, it is generally thought that they are interdependent technical, mechanical, conceptual and perceptual skills that are necessary to safely select and plan, prepare, and store nutritious and culturally-acceptable meals and snacks — Recommendations People with diabetes should receive nutrition counselling by a registered dietitian to lower A1C levels [Grade B, Level 2 3 , for those with type 2 diabetes; Grade D, Consensus, for type 1 diabetes] and to reduce hospitalization rates [Grade C, Level 3 8 ].
Nutrition education may be delivered in either a small group or one-on-one setting [Grade B, Level 2 18 ]. Group education should incorporate adult education principles, such as hands-on activities, problem solving, role playing and group discussions [Grade B, Level 2 19 ].
Individuals with diabetes should be encouraged to follow Eating Well with Canada's Food Guide in order to meet their nutritional needs [Grade D, Consensus].
In people with overweight or obesity with diabetes, a nutritionally balanced, calorie-reduced diet should be followed to achieve and maintain a lower, healthier body weight [Grade A, Level 1A 29,30 ]. An intensive healthy behaviour intervention program, combining dietary modification and increased physical activity, may be used to achieve weight loss, improve glycemic control and reduce CV risk [Grade A, Level 1A 30 ].
People with type 2 diabetes should maintain regularity in timing and spacing of meals to optimize glycemic control [Grade D, Level 4 ]. Adults with diabetes should select carbohydrate food sources with a low-GI to help optimize glycemic control [Grade B, Level 2 46,47 for type 1 diabetes; Grade B, Level 2 32,44 for type 2 diabetes], to improve LDL-C [Grade C, Level 3 49 ] and to decrease CV risk [Grade D, Level 4 52 ].
The following dietary patterns may be considered in people with type 2 diabetes, incorporating patient preferences, including: Mediterranean-style dietary pattern to reduce major CV events [Grade A, Level 1A ] and improve glycemic control [Grade B, Level 2 50, ].
Vegan or vegetarian dietary pattern to improve glycemic control [Grade B, Level 2 , ], body weight [Grade C, Level 3 ], and blood lipids, including LDL-C [Grade B, Level 2 ] and reduce myocardial infarction risk [Grade B, Level 2 ].
DASH dietary pattern to improve glycemic control [Grade C, Level 2 ], BP [Grade D, Level 4 — ], and LDL-C [Grade B, Level 2 , ] and reduce major CV events [Grade B, Level 3 ]. Dietary patterns emphasizing dietary pulses e. beans, peas, chickpeas, lentils to improve glycemic control [Grade B, Level 2 ], systolic BP [Grade C, Level 2 ] and body weight [Grade B, Level 2 ].
Dietary patterns emphasizing fruit and vegetables to improve glycemic control [Grade B, Level 2 , ] and reduce CV mortality [Grade C, Level 3 79 ]. Dietary patterns emphasizing nuts to improve glycemic control [Grade B, Level 2 ], and LDL-C [Grade B, Level 2 ].
Other Relevant Guidelines Chapter 7. Self-Management Education and Support Chapter Physical Activity and Diabetes Chapter Weight Management in Diabetes Chapter Complementary and Alternative Medicine for Diabetes Chapter Dyslipidemia Chapter Treatment of Hypertension Chapter Type 1 Diabetes in Children and Adolescents Chapter Type 2 Diabetes in Children and Adolescents Chapter Diabetes and Pregnancy Chapter Diabetes in Older People Chapter Type 2 Diabetes and Indigenous Peoples.
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If nutrients are lost due to gastric residual evaluation or if feeding is interrupted for medical procedures, the resulting gaps in nutrition will go uncompensated. The result: The feeding target will not be achieved, putting the patient at risk for malnutrition [1].
Optimal Protein and Energy nutrition decreases Mortality in Mechanically Ventilated, Critically Ill Patients: A Prospective Observational Cohort Study. Yearbook Of Surgery , , doi:
Opyimal therapy and counselling Optimal nutrient distribution an integral Glycogen replenishment for athletes of the dustribution and self-management nufrient diabetes. The goals of nutrition therapy are to maintain or improve quality of life and distribjtion and physiological health; and to prevent and treat acute- and long-term complications of diabetes, associated comorbid conditions and concomitant disorders. It is well documented that nutrition therapy can improve glycemic control 1 by reducing glycated hemoglobin A1C by 1. Canada is a country rich in ethnocultural diversity. More than ethnic origins were reported in Canada in the census.
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