Canadian Diabetes Association

Clinical Practice Guidelines

Nutrition Therapy
Chapter 11
Paula D. Dworatzek, Kathryn Arcudi,
Rjeanne Gougeon, Nadira Husein,
John L. Sievenpiper, Sandi Williams

Nutrition Checklist

2013

REFER for nutrition counseling by a registered

dietitian
FOLLOW Eating Well with Canadas Food Guide
INDIVIDUALIZE dietary advice based on preferences
and treatment goals
CHOOSE low glycemic index carbohydrate food
sources

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Nutrition Checklist (continued)

2013

KNOW alternative dietary patterns for type 2 diabetes

ENCOURAGE matching of insulin to carbohydrate in
type 1 diabetes
ENCOURAGE nutritionally balanced, calorie-reduced
diet in overweight or obese patients

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Encourage patients
to follow Eating
Well with Canadas
Food Guide in order
to meet their
nutritional needs
http://www.hc-sc.gc
.ca/fn-an/food-guid
e-aliment/indexeng.php

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Macronutrient Distribution (% Total Energy)

% of total
energy
Calories per
gram
Grams for 2000
calorie/day diet

Carbohydrates

Protein

Fat

45-60%

15-20%

20-35%

(or 1-1.5g / kg BW)

225-300

75-100

44-78

BW = body weight
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Choosing Foods Using % Daily Value

Daily Values > 15% = a lot

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Daily Value < 5% = a little

http://www.hc-sc.gc.ca/fn-an/labeletiquet/nutrition/cons/fact-fiche-eng.php

For Patients with BMI 25 kg/m2

Nutritionally balanced, calorie-reduced diet should
be followed to achieve and maintain a lower, healthier
body weight
Weight loss of 5-10% of initial body weight
Improved insulin sensitivity, glycemic control, blood
pressure control, lipid levels

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Choose low glycemic index carbohydrates

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www.guidelines.diabetes.ca

Figure 1 Nutritional management of hyperglycemia in type 2 diabetes

Clinical assessment

2013

Lifestyle intervention by Registered Dietitian

Initiate intensive lifestyle intervention or energy restriction + increased
physical activity to achieve/maintain a healthy body weight
Provide counselling on a diet best suited to the individual based on
preferences, abilities, and treatment goals using the advantages/disadvantages
listed below
If not at target

Continue lifestyle intervention and add pharmacotherapy

Timely adjustments to lifestyle intervention and/or
pharmacotherapy should be made to attain target A1C within 2
to 3 months for lifestyle intervention alone or 3-6 months for
any combination
with pharmacotherapy
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Properties of Macronutrients

2013

Dietary interventions

A1C

Advantages

Disadvantages

Hi-CHO
(low-glycemic index [GI])

HDL-C, CRP,
hypoglycemia

Hi-CHO
(high fibre)

TC, LDL-C

HDL-C,
GI side effects

Hi-MUFA

TG

Lo-CHO

TG

Micronutrients,
renal load

Hi-protein

BP, TG, preserve

lean mass

Micronutrients,
renal load

Long chain omega 3 fatty

acids

TG

Methyl-Hg exposure,
environmental impact

A1C = glycated hemoglobin

CRP = C reactive protein
TC = total cholesterol

CHO = carbohydrate
MUFA = monounsaturated fatty acid
LDL = low-density lipoprotein

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BP = blood pressure
TG = triglycerides
FPG = fasting plasma glucose

GI = gastrointestinal
= <1% decrease in A1C
HDL = high-density lipoprotein

Properties of Dietary Patterns

Dietary Pattern

A1C

2013

Advantages

Disadvantages

Vegetarian Diet

LDL-C, HDL-C

Vitamin B12

Mediterranean Diets

BP, CRP, TC, HDL-C,

TC:HDL-C, TG

none

DASH

Weight, BP, CRP, LDL-C,

HDL-C

none

Atkins diet

Weight, TC, HDL-C,

TC:HDL-C, TG

Protein Power Plan

Weight

LDL-C, micronutrients,
adherence
Micronutrients,
adherence, renal load

Ornish

Weight, LDL-C:HDL-C

FPG, adherence

Weight Watchers

Weight, LDL-C:HDL-C

FPG, adherence

Zone Diet

Weight, LDL-C:HDL-C

FPG, adherence

Dietary Pulses

TC, LDL-C

GI side effects

Nuts

LDL-C, apo-B, apo-B:apo-A1

none

Meal
Replacements
weight
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Temporary intervention

Recommendations 1 and 2
1. People with diabetes should receive nutrition
counseling by a registered dietitian to lower A1C
levels [Grade B, Level 2, for type 2 diabetes; Grade D, Consensus, for type 1
diabetes], and reduce hospitalization rates [Grade C, Level 2]
2. Nutrition education is effective when delivered in
either a small group or one-on-one setting [Grade B, Level
2]. Group education should incorporate adult education
principles, such as hands-on activities, problem
solving, role-playing, and group discussions [Grade B,
Level 2]

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Recommendations 3 and 4
3. Individuals with diabetes should be encouraged to
follow Eating Well with Canadas Food Guide in
order to meet their nutritional needs [Grade D, Consensus]
4. In overweight or obese people with diabetes a
nutritionally balanced, calorie reduced diet should
2013
be followed to achieve and maintain a lower,
healthier body weight [Grade A, Level 1A]

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Recommendations 5 and 6
5. In adults with diabetes, the macronutrient distribution
as a percentage of total energy can range from 452013 60% carbohydrate, 15-20% protein, and 20-35%
fat to allow for individualization of nutrition therapy
based on preference and treatment goals [Grade D,
consensus]

6. Adults with diabetes should consume no more than

7% of total daily energy from saturated fats [Grade D,
2013 Consensus] and should limit intake of trans fatty
acids to a minimum [Grade D, Consensus]
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Recommendations 7 and 8
7. Added sucrose or added fructose can be substituted
for other carbohydrates as part of mixed meals up to
a maximum of 10% of total daily energy intake,
provided adequate control of BG and lipids is
maintained [Grade C, Level 3]
8. People with type 2 diabetes should maintain
regularity in timing and spacing of meals to
optimize glycemic control [Grade D, Level 4]

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Recommendation 9
9. Dietary advice may emphasize choosing
carbohydrate food sources with a low glycemic
index to help optimize glycemic control [type 1 diabetes:
Grade B, Level 2; type 2 diabetes: Grade B, Level 2]

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Recommendation 10

2013

10. Alternative dietary patterns may be used in

people with T2DM to improve glycemic control,
(including):

Mediterranean-style dietary pattern [Grade B, Level 2]

Vegan or vegetarian dietary pattern [Grade B, Level 2]

Incorporation of dietary pulses (e.g., beans, peas, check

peas, lentils) [Grade B, Level 2]

Dietary Approaches to stop Hypertension (DASH) dietary

pattern [Grade B, Level 2]

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Recommendations 11 and 12
11. An intensive lifestyle intervention program
combining dietary modification and increased
physical activity may be used to achieve weight
loss and improvements in glycemic control, and
cardiovascular risk factors [Grade A, Level 1A]
12. People with type 1 diabetes should be taught how
to match insulin to carbohydrate quantity and
quality [Grade C, Level 2]; or should maintain
consistency in carbohydrate quantity and quality
[Grade D, Level 4]
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Recommendations 13
13. People using insulin or insulin secretagogues
should be informed of the risk of delayed
hypoglycemia resulting from alcohol consumed
with or after the previous evenings meal [Grade C, Level 3]
and should be advised on preventive actions such as
carbohydrate intake and/or insulin dose adjustments,
and increased BG monitoring [Grade D, Consensus].

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CDA Clinical Practice Guidelines

http://guidelines.diabetes.ca for professionals
1-800-BANTING (226-8464)
http://diabetes.ca for patients

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Copyright 2013 Canadian Diabetes Association