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JOSLIN DIABETES CENTER & JOSLIN CLINIC CLINICAL NUTRITION GUIDELINE FOR OVERWEIGHT AND OBESE ADULTS WITH TYPE 2 DIABETES, PREDIABETES OR THOSE AT HIGH RISK FOR DEVELOPING TYPE 2 DIABETES

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Copyright © 2011 by Joslin Diabetes Center. All rights reserved. Any reproduction of this document, which omits Joslin’s name or copyright notice is prohibited. This document may be
reproduced for personal use only. It may not be distributed or sold. It may not be published in any other format without the prior, written permission of Joslin Diabetes Center, Publications
Department, 617-226-5815.
1
JOSLIN DIABETES CENTER & JOSLIN CLINIC
CLINICAL NUTRITION GUIDELINE FOR OVERWEIGHT AND OBESE ADULTS WITH TYPE 2
DIABETES, PREDIABETES OR THOSE AT HIGH RISK FOR DEVELOPING TYPE 2 DIABETES
08 07 2011
The Joslin Clinical Nutrition Guideline For Overweight and Obese Adults With Type 2 Diabetes, Prediabetes or at High Risk for
Developing Type 2 Diabetes is designed to assist primary care physicians, specialists, and other healthcare providers in individualizing
the care of and set goals for adult, non-pregnant patients with type 2 diabetes or individuals at high risk for developing type 2 diabetes.
This guideline focuses on the unique needs of those individuals, and complements the 2010 Dietary Guidelines for Americans, which is
jointly developed by the Department of Health and Human Services and the Department of Agriculture. It is not intended to replace
sound medical judgment or clinical decision-making and may need to be adapted for certain patient care situations where more or less
stringent interventions are necessary.
The objectives of the Joslin Clinical Diabetes Guidelines are to support clinical practice and to influence clinical behaviors in order to
improve clinical outcomes and assure that patient expectations are reasonable and informed. Guidelines are developed and approved
through the Clinical Oversight Committee that reports to the Joslin Clinic Medical Director of Joslin Diabetes Center. The Clinical
Guidelines are established after careful review of current evidence, medical literature and sound clinical practice. These Guidelines will
be reviewed periodically and the Joslin Diabetes Center will maintain, upgrade or downgrade the rating for each recommendation when
new evidence mandates such changes.
Joslin’s Guidelines are evidence-based; in order to allow the user to evaluate the quality of the evidence used to support each standard of
care, a modification of the GRADE system has been adopted. The table provided on page 5 describes the categories in which
methodological quality and strength of recommendations have been classified. Evidence levels are graded 1A through 2C, as indicated
in brackets.
Target Individuals and General Goals of Clinical Nutrition Guideline
BMI > 25 kg/m2
or Waistline > 40”/102 cm (men)
[1B]
> 35”/88 cm (women)
and
Type 2 Diabetes
or
Prediabetes IGT (impaired glucose tolerance) [1A]
IFG (impaired fasting glucose)
or
High Risk for The Metabolic Syndrome (AHA/NHLBI criteria)
[1B]
Type 2 Diabetes Family history of type 2 DM (first degree
relative)
Confirmed diagnosis of insulin resistance
(e.g., high basal insulin)
*Target
Population
* For Asian populations (South Asian Indians, East Asians and Malays) a BMI >23 kg/m2 and a waistline >35”/90 cm
in men or >31”/80 cm in women is considered. [1B]
General Guidelines
There is strong evidence that weight reduction improves insulin sensitivity and glycemic control, lipid profile, and blood pressure in
type 2 diabetes and decreases the risk of developing type 2 diabetes in pre-diabetes and high-risk populations.
To select an approach for medical nutrition therapy (MNT), target individuals should be referred to a registered dietitian (RD) or a
qualified healthcare provider for assessment and review of medical management and treatment goals. [1B]
Priorities of MNT for this population include:
1. Weight reduction
2. Meal to meal consistency in carbohydrate distribution for those with fixed medication/insulin programs
3. Consideration of other nutrition related co-morbidities such as hypertension and dyslipidemia
The meal plan composition, described below, is for general guidance only and may be individualized by the RD or other healthcare
provider according to clinical judgment, individual (patient) preferences and needs, and metabolic response. The plan should be re-
evaluated and modified to respond to changes in parameters such as blood pressure, A1C and frequency of hypo/hyperglycemia.
Modification of goals may be needed for those requiring additional dietary considerations such as those with hyperkalemia or who
are vegetarian.
Copyright © 2011 by Joslin Diabetes Center. All rights reserved. Any reproduction of this document, which omits Joslin’s name or copyright notice is prohibited. This document may be
reproduced for personal use only. It may not be distributed or sold. It may not be published in any other format without the prior, written permission of Joslin Diabetes Center, Publications
Department, 617-226-5815.
2
Weight Reduction
1. A structured lifestyle plan that combines dietary modification, activity, and behavioral modification is necessary for weight
reduction. [1B]
2. A modest and gradual weight reduction of one to two pounds every one to two weeks should be the optimal target. [2A].
Reduction of daily caloric intake should be by range between 250 - 500 calories. [1C] Total daily caloric intake should not be less
than 1000-1200 for women and 1200-1600 for men, or based on a RD assessment of usual intake. [1C]
3. A 5-10% weight loss may result in significant improvement in blood glucose control among patients with diabetes and help
prevent the onset of diabetes among individual with pre-diabetes. Weight reduction should be individualized and continued until
an agreed upon BMI and/or other metabolic goals are reached. [2B]
4. Target individuals should meet with RD to learn and practice portion control as an effective way of weight management. [1B]
5. Meal replacements (MR)** in the form of shakes, bars, ready-to-mix powders, and pre-packaged meals that match these nutrition
guidelines may be effective in initiating and maintaining weight loss [2 B]
Meal replacements should be used under the supervision of a RD.
When meal replacements are initiated, glucose levels should be carefully monitored and if needed, antihyperglycemic
medications should be adjusted
** meal replacements should be used with caution by those with hyperkalemia
7. Bariatric surgeries, although not without medical and nutrition risks, are effective options and may be discussed when indicated
(consider in individuals with BMI >40 kg/m2 and those with BMI >35 kg/m2 with other comorbidities). [2B]. To date, there is
limited evidence to support the recommendation of bariatric surgeries for patients with BMI <35 kg/m2 even if they have diabetes
or other co-morbid conditions.
Macronutrient Composition
Percentage There is general agreement that fat quality rather than quantity is important. The total fat intake
should be generally limited to less than 35 % of total daily caloric intake [2B]
Saturated fat should be limited to < 7% of total caloric intake.[1B]
Polyunsaturated and monounsaturated fats should comprise the rest of the fat intake [2B)]
Cholesterol limited to <300 mg/day or <200 mg/day in individuals with LDL-Cholesterol
>100 mg/dl. [1C]
Fat
Recommended
Not Recommended
Mono and polyunsaturated fats (e.g., olive oil, canola oil, nuts/seeds, avocado and fish,
particularly those high in omega-3 fatty acids). 4 oz of oily fish (e.g., salmon, herring, trout,
sardines, fresh tuna) 2 times/week, as a source of omega-3 fatty acids. [1B]
Foods high in saturated fat, including beef, pork, lamb and high-fat dairy products (e.g., cream
cheese, whole milk or yogurt)
Foods high in trans-fats (e.g., fast foods, commercially baked goods, some margarines)
Foods high in dietary cholesterol such as egg yolks, and organ meats.
Grams/day Protein intake should not be less than 1.2 gm/kg of adjusted body weight Adjusted Body
Weight = IBW (Ideal Body Weight) + 0.25 (Current Weight - IBW). This amount generally
accounts for 20-30% of total caloric intake [2B] There are no reliable scientific findings to
support a protein intake that exceeds 2 gm/kg of adjusted body weight.
Emerging data suggest that protein aids in the sensation of fullness (low-protein meal plans are
associated with increased hunger). A modest increase in protein reduces appetite and assists in
achieving and maintaining weight reduction. [2B] Protein also helps to minimize loss of lean
body mass. [2 B]
Recommended
Not Recommended
Fish, skinless poultry, nonfat or low-fat dairy, nuts, seeds, and legumes [2B]
High saturated fat protein sources in excess (e.g., beef, pork, lamb and high-fat dairy products),
as they may be associated with increased cardiovascular risk.
Protein
Patients with
Renal Issues Although reducing total calories may result in a reduction of the absolute total amount of
protein intake, patients with signs of kidney disease (i.e., one or more of the following:
proteinuria, GFR<60 ml/min) should consult a nephrologist before increasing total or
percentage protein in their diet. [1B] Protein intake for these patients should be modified, but
not lowered to a level that may jeopardize their overall health or increase their risk for
malnutrition or hypoalbuminemia.
Copyright © 2011 by Joslin Diabetes Center. All rights reserved. Any reproduction of this document, which omits Joslin’s name or copyright notice is prohibited. This document may be
reproduced for personal use only. It may not be distributed or sold. It may not be published in any other format without the prior, written permission of Joslin Diabetes Center, Publications
Department, 617-226-5815.
3
Macronutrient Composition (continued)
Percentage
Intake should be adjusted to meet the cultural and food preferences of the individual.
The total daily intake of carbohydrate should be at least 130 gm/day and ideally 40-45% of
the total caloric intake[1C]
Consideration of
Glycemic
Index/Glycemic
Load
The glycemic index/glycemic load is an important factor that patients should apply in their
daily selection of carbohydrates foods. Foods with a low glycemic index should be selected
[2B] (e.g.,whole grains, legumes, fruits, green salad with olive oil-based dressing, and most
vegetables )
Recommended
Not Recommended
Vegetables and fruits, legumes, whole and minimally processed grains. [2B]
Sugar, refined carbohydrates or processed grains and starchy foods especially sugary beverages,
most pastas, white bread, white rice, low-fiber cereal and white potatoes should be consumed in
limited quantities. [2B]
Carbohydrate
Fiber Approximately 14gm of fiber /1000 cal (20-35 gm) per day is recommended. [1B] If
tolerated, ~50 gm/day is effective in improving postprandial hyperglycemia and should be
encouraged. [2A]
Fiber from unprocessed food, such as vegetables, fruits, seeds, nuts, and legumes is
preferable but, if needed, fiber supplements such as psyllium, resistant starch and β-glucan
can be added. [1B]
Micronutrient Composition
Sodium Daily consumption should be < 2300 mg (about 1 tsp of salt) per day. (1A) Further
reduction to 1500 mg is recommended in people > 50 yr of age including those with chronic
kidney disease. [2B]
Slow acclimatization to lower sodium intakes is advisable.
Potassium
Daily consumption should be a minimum of 4,700 mg unless potassium excretion is
impaired
Potassium helps offset high sodium intake by triggering more sodium excretion by the
kidneys.
Potassium-rich foods include fruits and vegetables like bananas, mushrooms, spinach, and
almonds.
Dietary Supplements
In individuals who are not deficient, data do not support the use of vitamins or minerals to improve glucose control or the use of herbal
supplements or spices to improve glucose control.
Non-nutritive Sweeteners
All FDA- approved non-nutritive sweeteners are permissible in moderate quantities (e.g., one diet soda daily)
Alcohol
If consumed, alcohol consumption must be moderate. No more than 1 drink a day for women and no more than 2 drinks a day
for men (one drink is equal to 12 ounces of regular beer, 5 ounces of wine, or 1.5 ounces of 80-proof distilled alcohol). [2C]
Alcoholic beverages contain calories and are low in nutritional value.
It is not advisable to increase alcohol consumption for the purpose of deriving purported health benefit.
Physical Activity and Behavioral Modification
Physical activity should be included in the nutrition prescription described above. Increased physical activity should be an
integral component of any weight reduction plan as it helps maximize the benefits of weight reduction on diabetes control and
may prevent coronary and cerebral vascular disease. [1B]
60-90 minutes of moderately intensive activity, at least 5 days of the week, is encouraged for weight loss, unless contraindicated.
[1B]
Physical activity should be a mix of cardiovascular, flexibility, and resistance training to maintain or increase lean body mass.
Copyright © 2011 by Joslin Diabetes Center. All rights reserved. Any reproduction of this document, which omits Joslin’s name or copyright notice is prohibited. This document may be
reproduced for personal use only. It may not be distributed or sold. It may not be published in any other format without the prior, written permission of Joslin Diabetes Center, Publications
Department, 617-226-5815.
4
Appendix A
Suggested Approximate Macronutrient Distribution
According to Clinical Guideline
Calorie Level Carbohydrate Protein Fat
Grams % Grams % Grams %
1000 130 ~50 * 75 30 27 20
1200 135 45 75-90 25-30 40 30
1500 150-170 40-45 75-110 20-30 50 30
1800 180-200 40-45 90-135 20-30 60 30
2000 200-225 40-45 100-150 20-30 70 ~30
*A minimum of 130grams of carbohydrate per day, in a 1000 calorie meal plan, calculates to ~50% of the total daily calories.
Approved by the Joslin Clinical Oversight Committee on 08 07 2011
Clinical Nutrition Task Force
Om Ganda, MD Co-Chair
Osama Hamdy, MD, PhD-Co-Chair
Gillian Arathuzik, MS, RD, CDE
Elizabeth Blair, MSN, ANP-BC, CDE
Cathy Carver, MSN, ANP-BC, CDE
Amy Campbell, MS, RD, CDE
Aaron Cypess, MD, PhD
Edward S. Horton, MD
Richard Jackson, MD
Sharon Jackson , MS, RD, CDE
Amanda Kirpitch, RD, CDE
Melinda Maryniuk, MEd, RD, CDE
Jo-Anne Rizzotto, MEd,RD, CDE
Nuha El Sayed, MD
Nora Saul, MS, RD, CDE
Joslin Clinical Oversight Committee
Om Ganda, MD -Chairperson
Richard Beaser, MD
Elizabeth Blair, MSN, ANP-BC, CDE
Amy Campbell, MS, RD, CDE
Cathy Carver, MSN, ANP-BC, CDE
Jerry Cavallerano, OD, PhD
William Hsu, MD
Richard Jackson, MD
Lori Laffel, MD, MPH
Medha Munshi, MD
Melinda Maryniuk, MEd, RD, CDE
Jo-Anne Rizzotto, Med,RD, CDE
Bijan Roshan, MD
Susan Sjostrom, JD
Kenneth Snow, MD
William Sullivan, MD
Howard Wolpert, MD
John Zrebiec, LICSW, CDE
Martin Abrahamson, MD (ex officio)
Copyright © 2011 by Joslin Diabetes Center. All rights reserved. Any reproduction of this document, which omits Joslin’s name or copyright notice is prohibited. This document may be
reproduced for personal use only. It may not be distributed or sold. It may not be published in any other format without the prior, written permission of Joslin Diabetes Center, Publications
Department, 617-226-5815.
5
Grading System Used in Guideline
Grade of Recommendation Clarity of risk/benefit Quality of supporting evidence
1A
Strong recommendation
High quality of evidence
Benefits clearly outweigh risk
and vice versa.
Consistent evidence from well performed randomized,
controlled trails or overwhelming evidence of some other
form. Further research is unlikely to change our confidence in
the estimate of benefit and risk.
1B
Strong recommendation
Moderate quality of evidence
Benefits clearly outweigh risk
and burdens, or vice versa.
Evidence from randomized, controlled trials with important
limitations (inconsistent results, methodological flaws,
indirect or imprecise), or very strong evidence of some other
research design. Further research is likely to have an impact
on our confidence in the estimate of the benefit and risk and
may change the estimate.
1C
Strong recommendation
Low quality of evidence
Benefits outweigh risk and
burdens, or vice versa.
Evidence from observational studies, unsystematic clinical
experience, or from randomized controlled trails with serious
flaws. Any estimate of effect is uncertain.
2A
Weak recommendation
High quality of evidence
Benefits closely balanced with
risks and burdens.
Consistent evidence from well performed randomized
controlled trials or overwhelming evidence of some other
form. Further research is unlikely to change our confidence in
the estimate of benefit and risk.
2B
Weak recommendation
Moderate quality of evidence
Benefits closely balanced with
risks and burdens; some
uncertainly in the estimates of
benefits, risks and burdens.
Evidence from randomized controlled trials with important
limitations (inconsistent results, methodological flaws,
indirect or imprecise), or very strong evidence of some other
research design. Further research is likely to have an impact
on our confidence in the estimate of benefit and risk and may
change the estimate.
2C
Weak recommendation
Low quality of evidence
Uncertainty in the estimates of
benefits, risks and burdens;
benefits may be closely balanced
with risks and burdens.
Evidence from observational studies, unsystematic clinical
experience, or from randomized controlled trails with serious
flaws. Any estimate of effect is uncertain.
Evidence graded less than “A” is acceptable to support clinical recommendations in a guideline. It is also assumed that for many
important clinical recommendations, it would be unlikely that level A evidence be obtained because appropriate studies may never be
performed.
1
Guyatt G et al. Grading strength of recommendations and quality of evidence in clinical guidelines: Report from an American College of
Physicians Task Force. Chest 129:174-181, 2006.
Copyright © 2011 by Joslin Diabetes Center. All rights reserved. Any reproduction of this document, which omits Joslin’s name or copyright notice is prohibited. This document may be
reproduced for personal use only. It may not be distributed or sold. It may not be published in any other format without the prior, written permission of Joslin Diabetes Center, Publications
Department, 617-226-5815.
6
References.
1. Anderson JW, Gustafson NJ, Bryant CA, Tietyan-Clark J. Dietary fiber and diabetes: A comprehensive review and practical application. J Am
Diet Assoc, 1987; 87(9):1189-97.
2. Andrews RC, Cooper AR, Montgomery AA, et al. Diet or diet plus physical activity versus usual care in patients with newly diagnosed type 2
diabetes: the Early ACTID randomised controlled trial. Lancet 2011; published online June 25. DOI:10.1016/S0140-6736(11)60442-X.
3. Baba NH, Sawaya S, Torbay N, Habbal Z, Azar S, Hashim SA. High protein vs high carbohydrate hypoenergetic diet for the treatment of obese
hyperinsulinemic subjects. Int J Obes Relat Metab Disord, 1999;23(11):1202-1206.
4. Biesalski HK. Diabetes preventive components in the Mediterranean diet. Eur J Nutr, 2004;43 Suppl 1:I/26-30.
5. Brehm BJ, Seeley RJ, Daniels SR, D'Alessio DA. A randomized trial comparing a very low carbohydrate diet and a calorie-restricted low fat diet
on body weight and cardiovascular risk factors in healthy women. J Clin Endocrinol Metab, 2003;88:1617-23.
6. Brinkworth GD, Noakes M, Parker B, Foster P, Clifton PM. Long-term effects of advice to consume a high-protein, low-fat diet, rather than a
conventional weight-loss diet, in obese adults with type 2 diabetes: one-year follow-up of a randomised trial. Diabetologia, 2004;47(10):1677-86.
7. Chandalia M, Garg A, Lutjohann D, von Bergmann K, Grundy SM, Brinkley LJ. Beneficial effects of high dietary fiber intake in patients with
type 2 diabetes mellitus. N Engl J Med, 2000;342:1392-1398.
8. Dansinger ML, Gleason JA, Griffith JL, Selker HP, Schaefer EJ. Comparison of the Atkins, Ornish, Weight Watchers, and Zone diets for weight
loss and heart disease risk reduction: a randomized trial. JAMA, 2005;293(1):43-53.
9. DeCaterina Drug therapy: n-3 fatty acids in cardiovascular disease. NEJM 2011; 364: 2439-2450
10. Diabetes Prevention Program Research Group. Reduction in the Incidence of Type 2 Diabetes with Lifestyle Intervention or Metformin. N Eng J
Med, 2002;346(6):393-403.
11. Dixon JB, O'Brien PE. Health outcomes of severely obese type 2 diabetic subjects 1 year after laparoscopic adjustable gastric banding. Diabetes
Care, 2002;25(2):358-63.
12. Dumesnil JG, Turgeon J, Tremblay A, Poirier P, Gilbert M, Gagnon L, St-Pierre S, Garneau C, Lemieux I, Pascot A, Bergeron J, Despres JP.
Effect of a low-glycaemic index--low-fat--high protein diet on the atherogenic metabolic risk profile of abdominally obese men. Br J Nutr,
2001;86(5):557-68.
13. Ferchak CV, Meneghini LF. Obesity, bariatric surgery and type 2 diabetes--a systematic review. Diabetes Metab Res Rev, 2004;20(6):438-45.
14. Foster GD, Wyatt HR, Hill JO, Makris AP, Rosenbaum DL, Brill C, Stein RI, Mohammed BS, Miller B, Rader DJ, Zemel B, Wadden
TA, Tenhave T, Newcomb CW, Klein S. Weight and metabolic outcomes after 2 years on a low-carbohydrate versus low-fat diet: a randomized
trial. Ann Intern Med. 2010;153(3):147-57
15. Foster GD, Wyatt HR, Hill JO, McGuckin BG, Brill C, Mohammed BS, Szapary PO, Rader DJ, Edman JS, Klein S. A randomized trial of a low-
carbohydrate diet for obesity. N Engl J Med, 2003;348(21):2082-90.
16. Fukagawa NK, Anderson JW, Hageman G, Young VR, Minaker KL. High-carbohydrate, high-fiber diets increase peripheral insulin sensitivity in
healthy young and old adults. Am J Clin Nutr, 1990;52:524-8.
17. Gannon MC, Nuttall FQ, Saeed A, Jordan K, Hoover H. An increase in dietary protein improves the blood glucose response in persons with type
2 diabetes. Am J Clin Nutr, 2003;78(4):734-41.
18. Gannon MC, Nuttall FQ. Effect of a high-protein, low-carbohydrate diet on blood glucose control in people with type 2 diabetes. Diabetes,
2004;53(9):2375-82.
19. Hamdy O, Horton ES. Protein Content in Diabetes Nutrition Plan. Curr Diab Rep. 2011 Jan 5. [Epub ahead of print]
20. Hamdy O, Ledbury S, Mullooly C, Jarema C, Porter S, Ovalle K, Moussa A, Caselli A, Caballero AE, Economides PA, Veves A, Horton ES.
Lifestyle modification improves endothelial function in obese subjects with the insulin resistance syndrome. Diabetes Care, 2003; 26(7): 2119-
25.
21. Hamdy, O, Morsi,A, El-Sayed,N et al Long-term weight reduction in clinical practice after non- surgical diabetes weight management program.
Diabetes 2011, 60(suppl1): A515
22. Hu FB, Stampfer MJ, Manson JE, et al. Dietary fat intake and the risk of coronary heart disease in women. N Engl J Med, 1997;337:1491–9.
23. Hu FB. Plant-based foods and prevention of cardiovascular disease: an overview. Am J Clin Nutr, 2003;78(3 Suppl):544S-551S.
24. Johnston CS, Tjonn SL, Swan PD. High-protein, low-fat diets are effective for weight loss and favorably alter biomarkers in healthy adults. J
Nutr, 2004;134(3):586-91.
25. Keno Y, Matsuzawa Y, Tokunaga K, Fujioka S, Kawamoto T, Kobatake T, Tarui S. High sucrose diet increases visceral fat accumulation in
VMH-lesioned obese rats. Int J Obes, 1991;15(3):205-11.
26. Kim JY, Nolte LA, Hansen PA, Han DH, Ferguson K, Thompson PA, Holloszy JO. High-fat diet-induced muscle insulin resistance: relationship
to visceral fat mass. Am J Physiol Regul Integr Comp Physiol, 2000;279(6):R2057-65.
27. Lara-Castro, C , Garvey, T. Diet, insulin resistance, and obesity: Zoning in on data for Atkins dieters living in South Beach. J Clin Endocrinol
Metab, 2004;89:4197-4205.
28. Larsen TM, Dalskov SM, van Baak M, Jebb SA, Papadaki A, Pfeiffer AF, Martinez JA, Handjieva-Darlenska T, Kunešová M, Pihlsgård
M, Stender S, Holst C, Saris WH, Astrup A; Diet, Obesity, and Genes (Diogenes) Project. Diets with high or low protein content and glycemic
index for weight-loss maintenance. N Engl J Med. 2010;363(22):2102–13.
29. Look AHEAD Research Group. Long-term eff ects of a lifestyle intervention on weight and cardiovascular risk factors in individuals with type 2
diabetes mellitus: four-year results of the Look AHEAD trial. Arch Intern Med 2010; 170: 1566–75. .
30. Ludwig DS, Pereira MA, Kroenke CH, et al. Dietary fiber, weight gain, and cardiovascular disease risk factors in young adults. JAMA, 1999;
282:1539-46.
31. Ludwig DS. Dietary glycemic index and obesity. J Nutr, 2000;130:280S–3S.
32. Luscombe ND, Clifton PM, Noakes M, Parker B, Wittert G. Effects of energy-restricted diets containing increased protein on weight loss, resting
energy expenditure, and the thermic effect of feeding in type 2 diabetes. Diabetes Care, 2002;25(4):652-7.
33. Mann JI. Diet and risk of coronary heart disease and type 2 diabetes. Lancet, 2002;360(9335):783-9.
34. Meckling KA, O'Sullivan C, Saari D. Comparison of a low-fat diet to a low-carbohydrate diet on weight loss, body composition, and risk factors
for diabetes and cardiovascular disease in free-living, overweight men and women. J Clin Endocrinol Metab, 2004;89(6):2717-23.
Copyright © 2011 by Joslin Diabetes Center. All rights reserved. Any reproduction of this document, which omits Joslin’s name or copyright notice is prohibited. This document may be
reproduced for personal use only. It may not be distributed or sold. It may not be published in any other format without the prior, written permission of Joslin Diabetes Center, Publications
Department, 617-226-5815.
7
35. Misra A, Wasir JS, Pandey RM. An evaluation of candidate definitions of the metabolic syndrome in adult Asian Indians. Diabetes Care
2005;28(2):398-403.
36. McAuley KA, Hopkins CM, Smith KJ, McLay RT, Williams SM, Taylor RW, Mann JI. Comparison of high-fat and high-protein diets with a
high-carbohydrate diet in insulin-resistant obese women. Diabetologia, 2005;48(1):8-16.
37. Park, Y , Subar, AF, Hollenbeck, A Schatzkin,A Dietary fiber intake and mortality in the NIH-AARP Diet and Health study. Arch Intern Med
2011; 171:1061-1068
38. Parker B, Noakes M, Luscombe N, Clifton P. Effect of a high-protein, high-monounsaturated fat weight loss diet on glycemic control and lipid
levels in type 2 diabetes. Diabetes Care, 2002;25(3):425-30.
39. Pereira MA, Swain J, Goldfine AB, Rifai N, Ludwig DS. Effects of a low glycemic load diet on resting energy expenditure and heart disease risk
factors during weight loss. JAMA 2004;292:2482-90.
40. Rock CL, Flatt SW, Sherwood NE, Karanja N, Pakiz B, Thomson CA. Effect of a free prepared meal and incentivized weight loss program on
weight loss and weight loss maintenance in obese and overweight women: a randomized controlled trial. JAMA.
2010;304(16):doi:10.1001/jama.2010.1503
41. Skov AR, Toubro S, Ronn B, Holm L, Astrup A. Randomized trial on protein vs carbohydrate in ad libitum fat reduced diet for the treatment of
obesity. Int J Obes Relat Metab Disord, 1999;23(5):528-36.
42. Sofi, F Cesari, F, Abbate, R et al Adherence to Mediterranean diet and health status: a meta analysis. BMJ 2008; 337: a1344
43. Stern L, Iqbal N, Seshadri P, Chicano KL, Daily DA, McGrory J, Williams M, Gracely EJ, Samaha FF. The effects of low-carbohydrate versus
conventional weight loss diets in severely obese adults: one-year follow-up of a randomized trial. Ann Intern Med, 2004;140(10):778-85.
44. Story L, Anderson JW, Chen WJ, Karounos D, Jefferson B. Adherence to high-carbohydrate, high-fiber diets: Long-term studies of non-obese
diabetic men. J Am Diet Assoc, 1985;85(9):1105-10.
45. Suzukawa M. Abbey M. Howe PR. Nestel PJ. Effects of fish oil fatty acids on low density lipoprotein size, oxidizability, and uptake by
macrophages. J Lipid Res, 1995;36(3):473-84.
46. Uusitupa M, Lindi V, Louheranta A, Salopuro T, Lindstrom J, Tuomilehto J; Finnish Diabetes Prevention Study Group. Long-term improvement
in insulin sensitivity by changing lifestyles of people with impaired glucose tolerance: 4-year results from the Finnish Diabetes Prevention Study.
Diabetes, 2003;52(10):2532-8.
47. Yang,Q Liu, T, Kuklina,EV et al Sodium and potassium intake and mortality among US adults. Prospective data from Third NHANES. Arch
Intern Med 2011; 171: 1183-1191
48. Yip I, Go VL, DeShields S, Saltsman P, Bellman M, Thames G, Murray S, Wang HJ, Elashoff R, Heber D. Liquid meal replacements and
glycemic control in obese type 2 diabetes patients. Obes Res, 2001;9 Suppl 4:341S-347S..
... Por otro lado, están las dietas populares, donde algunas tienen como objetivo promover la pérdida de peso y otras como las vegetarianas, fomentar un estilo de vida en particular (Centurión-Bernal, González-Acosta, Rojas-Pavón, Burgos-Larroza & Meza-Miranda, 2018). El Centro de Investigación para la diabetes Joslin de EUA (Hamdy, 2011) sugiere que perder entre 5 a 10% del peso inicial mejora de forma significativa el control de la glucosa en sangre en pacientes con diabetes y ayuda en la prevención de la prediabetes. En México, se sugiere que los pacientes con obesidad (IMC >30 kg/m2) podrán tener una restricción energética de 20 a 25 kcal/día con base en el "peso ideal". ...
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Lifestyle changes soon after diagnosis might improve outcomes in patients with type 2 diabetes mellitus, but no large trials have compared interventions. We investigated the effects of diet and physical activity on blood pressure and glucose concentrations. We did a randomised, controlled trial in southwest England in adults aged 30-80 years in whom type 2 diabetes had been diagnosed 5-8 months previously. Participants were assigned usual care (initial dietary consultation and follow-up every 6 months; control group), an intensive diet intervention (dietary consultation every 3 months with monthly nurse support), or the latter plus a pedometer-based activity programme, in a 2:5:5 ratio. The primary endpoint was improvement in glycated haemoglobin A(1c)(HbA(1c)) concentration and blood pressure at 6 months. Analysis was done by intention to treat. This study is registered, number ISRCTN92162869. Of 593 eligible individuals, 99 were assigned usual care, 248 the diet regimen, and 246 diet plus activity. Outcome data were available for 587 (99%) and 579 (98%) participants at 6 and 12 months, respectively. At 6 months, glycaemic control had worsened in the control group (mean baseline HbA(1c) percentage 6·72, SD 1·02, and at 6 months 6·86, 1·02) but improved in the diet group (baseline-adjusted difference in percentage of HbA(1c) -0·28%, 95% CI -0·46 to -0·10; p=0·005) and diet plus activity group (-0·33%, -0·51 to -0·14; p<0·001). These differences persisted to 12 months, despite less use of diabetes drugs. Improvements were also seen in bodyweight and insulin resistance between the intervention and control groups. Blood pressure was similar in all groups. An intensive diet intervention soon after diagnosis can improve glycaemic control. The addition of an activity intervention conferred no additional benefit. Diabetes UK and the UK Department of Health.
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Dietary fiber has been hypothesized to lower the risk of coronary heart disease, diabetes, and some cancers. However, little is known of the effect of dietary fiber intake on total death and cause-specific deaths. We examined dietary fiber intake in relation to total mortality and death from specific causes in the NIH (National Institutes of Health)-AARP Diet and Health Study, a prospective cohort study. Diet was assessed using a food-frequency questionnaire at baseline. Cause of death was identified using the National Death Index Plus. Cox proportional hazard models were used to estimate relative risks and 2-sided 95% confidence intervals (CIs). During an average of 9 years of follow-up, we identified 20 126 deaths in men and 11 330 deaths in women. Dietary fiber intake was associated with a significantly lowered risk of total death in both men and women (multivariate relative risk comparing the highest with the lowest quintile, 0.78 [95% CI, 0.73-0.82; P for trend, <.001] in men and 0.78 [95% CI, 0.73-0.85; P for trend, <.001] in women). Dietary fiber intake also lowered the risk of death from cardiovascular, infectious, and respiratory diseases by 24% to 56% in men and by 34% to 59% in women. Inverse association between dietary fiber intake and cancer death was observed in men but not in women. Dietary fiber from grains, but not from other sources, was significantly inversely related to total and cause-specific death in both men and women. Dietary fiber may reduce the risk of death from cardiovascular, infectious, and respiratory diseases. Making fiber-rich food choices more often may provide significant health benefits.