Position Statement

Dietary management ofpeople with diabetesmellitusAssociation for Dietetics in SouthernAfrica (ADSA)

This ADSA Position Statement is a revision of the 1992Statement entitled 'Nutritional recommendations forindividuals with diabetes mellitus'. Revisions have beenmade in the light of new research data.

AimThe aim of these recommendations is to encourage auniform approach to the nutritional management of diabetesin South Africa.

Although the implementation of these recommendationswill vary according to intake of traditional, ethnic and culturalfoods, these recommendations apply to all populationgroups, and should be tailored to individual needs,circumstances and preferences.

Objectives• To achieve optimal blood glucose concentrations.• To achieve optimal blood lipid concentrations.• To provide appropriate energy for reasonable weight,

Authors: A M Badenhorst, Department of Human Nutrition, Universityof the Orange Free State, BJoemfontein; J Badham, Director. J BConsultancy; R B1aauw, Department of Human Nutrition, Universityof Stellenbosch, Tygerberg; A Dannhauser, Department of HumanNubition, University of the Orange Free State, Bloemfontein; W duToit, oepal1ment of Human Nutrition, University of the Orange FreeState, BJoemfontein; C Herbert. South African Sugar Association.Public Affairs Division, Nutrition Department, Durban; J Johnson,Private practice, Rondebosch. and Centre for Diabetes andEndocrinology, Claremont, Cape Town; P A Joubert, Department ofHuman Nutrition, University of Stellenbosch, Tygerberg, andTygerberg Hospital; E Menssink, Private practice, Pretoria;C Peberdv, Centre for Diabetes and Endocrinology, Parktown,Johannesburg; N Silvis, Potchefstroom University for CHE,Potchefstroom; M Slabber, Department of Human Nutrition,University of the Orange Free State, Bloemfontein; R Wilson, Centrefor Diabetes and Endocrinology, Parktown, Johannesburg

Diabetes and Diet Specialist Group: Association for Dietetics inSouthern Africa (ADSA); Society fCH" Endocrinology and Diabetes ofSouthern Africa (SEMDSA); Diabetes Education Society of SouthernAfrica (OESSA) Specialist Working Group

Corresponding author. Or A M Badenhorst. Department of HumanNutrition (24), Faculty of Heatth Sciences, University of the OrangeFree State, PO Box 339, Bloemfontein, 9300. TeI (051) 401-2869. Fax(051) 448-4649.

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SAMJClinical Nutrition

normal growth and development, and pregnancy andlactation.

• To prevent, delay and treat nutrition-related complications.• To improve health through optimal nutrition.

EnergyThe energy content of the diet should be prescribed toachieve and/or maintain a desirable/reasonable bodyweight.

For children and adolescents, enough energy should beprescribed for normal growth and development.

During pregnancy and lactation, appropriate adjustmentsshould be made to achieve optimal blood glucoseconcentrations and optimal weight g.ain, and to minimiseketone production.

CarbohydratesThe diet should provide 50 - 65% of the total daily energyintake as carbohydrate, from a variety of sources. The dailyconsumption of a diet high in complex carbohydrates, andideally containing approximately 3 g dietary fibre (non-starchpolysaccharides) per 1 000 kJ, is recommended.

Foods provide the best means of increasing dailyconsumption of both soluble and insoluble fibre to therecommended levels. It must be noted that increasing thefibre content of the diet may decrease insulin requirementsin some individuals.

More research is needed to determine the effect of thevery high carbohydrate content of some traditional diets onglycaemic control.

FatTotal fat, especially saturated fat, should be restricted. Totalfat should comprise < 30% of the total daily energy intake,with saturated fat < 10% of total, polyunsaturated fat < 10%(preferably 6 - 8%) of total, and mono-unsaturated fat thebalance.

A reduction in saturated fatty acids is usually associatedwith a reduction in intake of dietary cholesterol. Moreresearch is needed to define the potential value of theadditional intake of mono-unsaturated fat and the use of fatsubstiMes.

ProteinThe protein content of the diet must be appropriate for thegrowth requirements, current nutritional status, age, bodyweight, and specific therapeutic needs of the individual.Protein should provide 10 - 20% of the total daily energyintake. Dietary protein should be derived from both animaland vegetable sources, in line with prudent diet guidelines.

With the onset of nephropathy, lower intakes of proteinshould be considered (0.8 g/kg/d) - approximately 10% ofthe total daily energy intake.

SAMJ Volume 87 No.9 xprember 1997 1233

Vitamins, minerals and traceelementsWhen a person with diabetes is under good metaboliccontrol and dietary intake is adequate, there is generally noneed for supplementation. In specific cases, supplementsmay be needed. This is only when a deficiency can bedemonstrated, when the person follows a very-low-energydiet, in uncontrolled diabetes, or in potential groups who areat risk.

There are theoretical reasons to supplement with anti­oxidants and chromium, but evidence for dailysupplementation is lacking and more research regarding thespecific role of these nutrients in diabetes is necessary.

SweetenersThe use of various nutritive and non-nutritive sweeteners inthe management of diabetes is acceptable. Umited amountsof sucrose and other nutritive sweeteners may be used aspart of an appropriate energy-controlled, high-fibre, low-fatdiet.

To distribute any potential risk, the use of a variety ofsweeteners in moderate amounts is recommended. Moreresearch, however, is needed to identify the effects of long­term use of non-nutritive sweeteners in humans, especiallyin children and pregnant and lactating women.

AlcoholLimited alcohol consumption is allowed in wefl-eontrolleddiabetes. Alcohol intake should not exceed 6 - 10% of thetotal daily energy intake, and alcohol must always beingested in combination wrth a meal.

Alcohol consumption is contraindicated in conditions suchas hypertriglyceridaemia, obesity, neuropathy, poorglycaemic control and pregnancy.

Meal frequencyA minimum of three meals should be ingested per day. Theprovision of snacks is determined by the type and time ofadministration of the medication, and the timing of the lastmeal of the day. In order to maintain eugtycaemia at alltimes, the ingestion of food must correlate with the durationof peak: action of the medication.

ExerciseRegular exercise should be a part of the Iffestyle of peoplewith non-insulin-<Jependent diabetes mallitus (NIDDM) andinsulin-<Jependent diabetes mellilus (IDDM).

Normal blood glucose concentrations should bemaintained before, during and after exercise. In lOOM,exercise can commence when blood glucose concentrationsare between 4 mmol/l and 14 mmol/l.

EducationMethods of education used must be tailored to individualneeds and abilities. Education must allow for individualitywithin the parameters of the dietary guidelines. Self-controlmust be encouraged through self-choice. A controlled dietplan should only be used when absolutely necessary.Regular follow-up, re-evaluation and counselling must beencouraged.

Pregnancy and lactationSuccessful pregnancy outcomes of women with diabetesdepend on adequate dietary intake, frequent glucosemonitoring, maintenance of optimal blood glucoseconcentrations, correct insulin management, and preventionof ketosis and hypoglycaemia.

Appetite, weight gain, blood glucose concentrations andinsulin requirements should be used as a guide to mealplanning. Energy, protein, carbohydrate and fat requirementsalter in pregnancy and lactation, and should be treatedindividually. Vitamin and mineral supplementation isrecommended where necessary. Meal frequency shouldcoincide with the insulin required, and the goal should bepostprandial blood glucose concentrations not exceeding6.6 mmoVl.

Suitable exercise, with the doctor's permission, is highlyrecommended. Breast-feeding should be encouraged. Bloodglucose concentrations must be monitored and additionalsnacks may be indicated during lactation.

ChildrenThe aim of the diet for children with diabetes is to promotenormal growth and development. Energy must be adequatefor normal growth and development. Total energyrequirements should be based on usual intake rather thantheoretical formulae.

Carbohydrate recommendations are similar to those foradults.The carbohydrate/fat ratio must be monitored as ahigh carbohydrate intake/prescription may necessitate alarge volume of food.

Fat intake should be according to the prudent dietaryguidelines for children older than 2 years of age. To satisfyenergy needs of the infant and toddler, fat intake should beup to 40% of total daily energy intake.

Protein intake should be the same as the RecommendedDietary Allowances (RDA), and be adequate for normalgrowth and development.

Foods that make diabeticclaimsAccording to legislation, a limited number of foods mayclaim that they are suitable for people with diabetes. Thesefoods are not essential in the diet of a person with diabetes,and should be used with discretion.

1234 Volume 87 No. 9 StpttmbtT 1997 SAMJ

Ensuring yournutritional health.

This ADSA Position Statement was adopted on 1 November1996, and replaces the 1992 Statement. The 1996 PositionStatement will be in effect until November 2000 unless review is

necessary prior to this date. AOSA authorises re-publication ofthis Position Statement, in its entirety, provided full and propercredit is given to ADSA.. Requests to use portions of thisPosition Statement must be made to the ADSA National Office,PO Box 1310, Cramerview, 2060.

BISUOGRAPHY

Acl 54 of 1972. No. R 3128, as amended on 20 December 1991. Regulations relatingto the use of sweeten81'S in foodstuffs. Government Gazerte 1991.

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American Diabetes Association. Magnesium supplementation in the treatment ofdiabetes. Diabetes Care 1993; 16: 1065-1067.

American Diabetes Association. Nutrition recommendations and principles for peoplewith diabetes mellitus. Diabetes Care 1994; 17: 519·522.

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American Dietetic Assoclation. Handbook 01 CUnical Dietetics. 2nd ed. Ne. Haven.Conn: Yale University Press. 1992.

American Diabetic Association. Position of the American Dietetic A$soCiation: use ofnutritive and non-nutritive sweeteners. J Am Diet Assoc 1993; 93: 816-821.

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British Diabetic Association. Dietary recommendations lor people with diabetes: anupdate for the 1990s. Diabetic Med 1992; 9: 189-202.

Brown L, Wilson D. Special needs: the athlete with diabetes. In: Butlte L, Oeakin V.eds. Clinical Sports Nutrition. Sydney: McGraw-Hill, 1994: 415·429.

Chalmers K. Nutrition basics lor the paediatric patient with diabetes mellitus. TheDiabetes Educ 1994; 20: 429-430.

Cummings J, Englyst H. GaslrointestinaJ effects of carbohydrate. Am J Clin Nurr1995; 61: 9385-945S.

Food and Drug Administration. Evaluation of Health Aspects of Sugan: Contained inCarbohydrate SwHteners.. Washington. DC: US FDA, 1996.

Food and Nutrition Board. National Research Colmcil. Recommended DfetfUyAIJoW8flces. Washington. DC: National Acadlmly Press, 1989.

Fnuu: MJ. Honon ES. Bantle JP. er al. Nutrition principles lor the mana~entofdiabetes and related complications. Diabetes Care 1994; 17: 490-518.

Frost G. Wilding J. Beecham J. Dietary advice based on the glycaemic inde:a:improves dietary profile and metabolil; control in type 2 diabetic patIents. DiabeticMed 1994; 11: 397-401.

Garg A. High-monCMlnsaturated lat diet tor diabetic patients: is it time to change thecurrent dietary recommendations? Diabetes Care 1994; 17: 242-246.

Holzmeistet L Baby food ellchanges and meal planning for the inlant with diabetes.The Diabetes Educ 1992; 18: 375-385.

Jenklns A, Jenkins D. Dietary fibre, glycaemic Indell and diabetes. S AIr Med J 1994;84: 36-37.

Jenkins A, Jenkins D. Nutrition principles and diabetes: a role for lente carbohydrate?Diabetes Care 1995; 18: 1491·1498.

Mahan L.., Arlin M. ~se's Food. Nutrition and Diet Therapy. 8th ed. Philadelphia:we Saunders, 1992.

Millet" J. Importance of gly(:aemic indell in diabetes. Am J Clin NlfU 1994; 59: 7475­752S.

Rude R. Magnesium deficiency and diabetes mellil\ls: causes and effects. PostgradMed 1992: 92: 217-224.

Umted States Department of Agriculture. Repon: Of rhe Oo'etary Guidelines AdvisoryCotnmiflee on W Dietary G/Jidelines for Americans. Washington. DC: Departmentof Agriculture, 1995.

Vessby B. Dietary ClIIbohydrates In diabetes. Am J Clin Huu 1994; 59: 7425-7465.Vinik A. Wirog R. The good. the bad and the ugly In diabetic diets. Endocrinol Merab

Clin North Am 1992; 21: 237-279. Whether you are 6 or 60, you may not

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