What Are The 10 Nutritional Guidelines

[Brian Bezdicek]

Thesedocuments are issued by the Food and Nutrition Board of the National Academies of Sciences Engineering, and Medicine. The Food and Nutrition Board addresses issues of safety, quality, and adequacy of the food supply; establishes principles and guidelines of adequate dietary intake; and renders authoritative judgments on the relationships among food intake, nutrition, and health.

The DRI Calculator for Healthcare Professionals is an interactive tool to calculate daily nutrient recommendations for dietary planning based on the Dietary Reference Intakes (DRIs) established by the Food and Nutrition Board of the National Academies of Sciences, Engineering and Medicine. While this data represents current scientific knowledge on nutrient needs, individual requirements may be higher or lower than the DRI recommendations.

Recommended intakes of nutrients vary by age and sex and are known as Recommended Dietary Allowances (RDAs) and Adequate Intakes (AIs). However, one value for each nutrient, known as the Daily Value (DV), is selected for the labels of dietary supplements and foods. A DV is often, but not always, similar to one's RDA or AI for that nutrient. DVs were developed by the U.S. Food and Drug Administration (FDA) to help consumers determine the level of various nutrients in a standard serving of food in relation to their approximate requirement for it. The label actually provides the %DV so that you can see how much (what percentage) a serving of the product contributes to reaching the DV.

The chapter summarizes the current information available from a variety of scientifically based guidelines and resources on dietary advice for those with diabetes. It is a practical overview for health care practitioners working in diabetes management. The chapter is divided into sections by content and includes sources for further reading. A primary message is that nutrition plans should meet the specific needs of the patient and take into consideration their ability to implement change. Often starting with small achievable changes is best, with larger changes discussed as rapport builds. Referral to medical nutrition therapy (MNT) provided by a Registered Dietitian Nutritionist (RDN) and a diabetes self- management education and support (DSMES) program is highlighted. For complete coverage of all related areas of Endocrinology, please visit our on-line FREE web-text, WWW.ENDOTEXT.ORG.

This chapter will summarize current information available from a variety of evidence-based guidelines and resources on dietary advice for those with diabetes. The modern diet for those with diabetes is based on concepts from clinical research, portion control, and individualized lifestyle change. It requires open and honest communication between health care practitioner and patient and cannot be delivered by giving a person a diet sheet in a one-size-fits- all approach. The lifestyle modification guidance and support needed most often requires a team effort, ideally including a registered dietitian (RD) or registered dietitian nutritionist (RDN), or a referral to a diabetes self- management education and support (DSMES) program that includes dietary advice. Current (2024) recommendations of the American Diabetes Association (ADA) promote all health care professionals to refer people with diabetes for individualized medical nutrition therapy (MNT) provided by an RDN at diagnosis and as needed throughout the life span, in addition to DSMES (1). It is very important to note that dietary recommendations for those with diabetes are virtually the same recommendations for diabetes prevention and the health of the general population; however, it cannot be excluded that people with diabetes will require additional support to meet the recommendations.

Fang et al, reported that although there has been continued improvements in risk factor control and adherence to preventative practices over the past decades, half of U.S. adults with diabetes do not meet the recommended goals for diabetes care in 2015-2018 (2). This is a current and ongoing issue. Diet and lifestyle recommendations are cornerstones of advice to prevent and manage diabetes, however there are recognized barriers to heeding advice and implementing lifestyle change. First, there is a plethora of dietary information for diabetes management available from many sources, although not all is evidence-based or current. There are also social, cultural, and personal preferences unique to each individual that must be taken into consideration when making long-term dietary change. Many health care practitioners are not adequately trained to be confident in delivering dietary advice, and many food environments do not support healthy dietary intakes for all. There are also commercial determinants of health that influence dietary intakes, such as marketing advertising, and price discounting on certain foods. The following recommendations come from evidence-based guideline development processes and emphasize practical suggestions for implementing dietary advice for most individuals with diabetes.

Dietary advice for those with diabetes has evolved and have become more flexible and patient centered over time. Nutrition goals from the American Diabetes Association (ADA) 2024 include the following: (1)

The primary goal in the management of diabetes is to achieve as near normal regulation of blood glucose as possible. Both the type and total amount of carbohydrate (CHO) consumed influences glycemia. Carbohydrate intake should emphasize nutrient-dense carbohydrate sources that are high in fiber (at least 14 g fiber per 1,000 kcal) and minimally processed (1). Dietary carbohydrate includes sugars, starch, and dietary fiber. Higher intakes of sugars are associated with weight gain and greater incidence of dental caries (5). Conversely, higher intakes of dietary fiber are associated with reduced non-communicable disease and premature mortality occurrence as well as improvements in body weight, cholesterol concentrations, and blood pressure (6, 7). These benefits with higher fiber intakes have been observed in the general population, for those with type 1, type 2, and pre diabetes, (8) and those with hypertension or heart disease (9). With this guidance in mind, eating plans should emphasize non-starchy vegetables, fruits, legumes, and whole grains, as well as dairy products with minimal added sugars (1, 10). There is less consistency of evidence for recommending an amount of overall CHO in the diet (1). This is in line with current World Health Organization for carbohydrate intakes for adults and children which stress the type of carbohydrate is important, with recommendations for fiber and vegetable and fruit intake, but no recommendations on CHO amount (7). Recent dietary guidelines for diabetes management from the European Association for the Study of Diabetes stress that a wide range of carbohydrate intakes can be appropriate, however both very high (>70%Total Energy (TE)) and low (

Resistant starches are starch enclosed within intact cell walls. These include some legumes, starch granules in raw potato, retrograde amylose from plants modified to increase amylose content, or high-amylose containing foods, such as specially formulated cornstarch, which are not digested and absorbed as glucose. Resistant starches avoid digestion in the small intestine so do not contribute to postprandial glycemia and diabetes risk, and are instead fermented in the colon by the microbiota.

Fructose is a naturally occurring monosaccharide found in fruits, some vegetables, and honey. High fructose corn syrup is used abundantly within the United States in processed foods as a less expensive alternative to sucrose. Fructose consumed in naturally occurring in foods such as fruit, (that also contain fiber) may result in better glycemic control compared with isocaloric intake of sucrose or fructose added to food, and is not likely to have detrimental effects on triglycerides as long as intake is not excessive (

A meta-analysis of 18 controlled feeding trials in people with diabetes compared the impact of fructose with other sources of carbohydrate on glycemic control. The analysis found that an isocaloric exchange of fructose for carbohydrates did not significantly affect fasting glucose or insulin and reduced glycated blood proteins in these trials of less than 12 weeks duration. The short duration is a potential limitation of the studies (19). Evidence exists that consuming high levels of fructose-containing beverages may have particularly adverse effects on selective deposition of ectopic and visceral fat, lipid metabolism, blood pressure, and insulin sensitivity compared with glucose-sweetened beverages (20). Thus, recommendations for dietary fructose tend to promote the reduction of fructose added to food, such as in fructose-containing beverages, while promoting whole fruit which can contain intrinsic fructose.

Non-nutritive sweeteners provide insignificant amounts of energy and elicit a sweet sensation without increasing blood glucose or insulin concentrations. There are several FDA-approved sweeteners found to be safe when consumed within FDA acceptable daily intake amounts (ADI) (Table 1) (21).

A review of 29 RCTs which included 741 people, 69 of which have type 2 diabetes, indicated that artificial sweeteners on their own do not raise blood glucose levels, but the content of the food or drink containing the artificial sweetener must be considered, especially for those with diabetes (22). This sentiment was echoed in recent WHO guidance on non-nutritive sweeteners for the general population (23) where their use was not recommended for weight loss, as the overall content of the processed food or drink was important.

In line with advice for the general public, people with diabetes should look to replace saturated and trans fats in the diet with mono and poly unsaturated fats (24). This is principally to lessen the increased risk of cardiovascular disease with high saturated and trans-fat intakes. Recent meta-analyses have found that decreasing the amount of saturated fatty acids and trans fatty acids, the principal dietary fatty acids linked to elevating LDL cholesterol, reduces the risk of CVD (25). The World Health Organization and American College of Cardiology currently recommend limiting the amount of dietary saturated and trans-fat intake (24, 26). Recommendations from the Institute of Medicine and the Academy of Nutrition and Dietetics for healthy individuals are that 20% to 35% of total energy should come from fat (27). Recommendations to reduce total fat intake are largely due to the high energy content of dietary fats, more so than protein or carbohydrate, and the risks associated with higher saturated fat intakes. Current recommendations for fat intakes from the American Diabetes Association focus on fat quality and its sources rather than quantity (1). They recommend:

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