Managing Type 2 Diabetes with Diet:
Beyond the American Diabetic Association (ADA) Recommendations

Most people understand that diet is important for managing type 2 diabetes, but don't realize how important it is.  Are you interested in getting off of your diabetic medications?  Reducing your dependence on medications?  Significantly improving your glycemic control and other markers of health? Carbohydrate counting, following exchange lists and other general ADA diet recommendations are better than continuing to follow the standard American diet, but you can make greater improvements in your health with more aggressive nutrition intervention that focuses on the underlying roots of the condition, instead of just the symptoms.

The standard diet information for managing type 2 diabetes that is given to patients is significantly lacking.  I think this is due to the usual conventional medical approach that uses a strict evidence-based medicine approach without balancing it with clinical reasoning, experience and analytical thinking as well as a focus on treating symptoms.  I do appreciate that the ADA is trying to promote a public health message for the larger diabetic audience, but as someone who has practiced conventional dietetics, this doesn’t serve individual patients very well and really under utilizes the power of food and nutrition.

In my view, there is plenty of research (including clinical trials) beyond the standard 50-60% calories from carbohydrates, low-fat, reduced calorie diet promoted by the ADA for managing type 2 diabetes.  Low glycemic impact, low carbohydrate, higher fat and fiber diets as well as certain micronutrients have been linked with improved health markers in type 2 diabetics.  Even to the point of reducing or eliminating dependence on medications. We’ll see where the research ultimately takes us, but in my view there’s a lot more evidence and reasoning out there to convey beyond the standard ADA diet recommendations for managing type 2 diabetes with diet.


Managing Type 2 Diabetes with Diet: The State of the Evidence

Low-fat or low carbohydrate?

Before the discovery of insulin, diabetics were advised to consume only 20% (or lower) of their total calories as carbohydrate since we know that glycemic control in diabetic subjects is greatly influenced by dietary carbohydrate content.   Over time, with the introduction of insulin and other diabetes related pharmaceuticals, low carbohydrate diabetic diet guidelines have evolved into low-fat, high carbohydrate diets.

We know from the Diabetes Prevention Program Group, that a standard low-fat, reduced calorie diet and lifestyle intervention can prevent the onset of type 2 diabetes in at-risk adults compared to minimal diet and lifestyle changes or medication alone. Overall, however, the low-fat, high carbohydrate trend has failed to curb the obesity and diabetes epidemic and long-term studies have found limited benefit of the low-fat dietary approach for preventing chronic disease.  Recent short and long-term randomized controlled trials and meta-analyses—considered the gold standards of research—have shown that low carbohydrate diets perform as well as or better than low-fat diets with regard to satiety and weight loss, glucose and insulin response, and important cardiovascular risk markers in both normal subjects and those with metabolic and other health conditions such as type 2 diabetes.  Recently, the landmark Look AHEAD study, a long-term randomized controlled trial in overweight type 2 diabetics, reported significant weight loss, lowered HbA1c and some cardiovascular risk factors in the intervention group versus the control group, but no reduction in cardiovascular events.  The intervention group focused on a standard low-fat, calorie restricted diet (with as much as 55% of calories coming from carbohydrate) and the emphasis appeared to be on quantity - counting fat grams and calories - and not quality. 

What is a low carbohydrate diet?  What about the “Paleo” diet for managing type 2 diabetes with diet?

There is no standardized definition of a low carbohydrate diet.  Most research with low carbohydrate diets are usually based on diets providing between 30-130 g of carbohydrates per day accompanied with a moderate amount of protein (15% to 30% of calories), with fats providing the rest of the daily energy requirements. It’s important to remember that the low carbohydrate diets studied in the scientific literature aren’t necessarily high-protein diets but rather higher-fat diets.

The “paleo” diet approach is really a type of low carbohydrate diet.  The limited studies in type 2 diabetics using a “paleo” specific diet and showing positive associations have contained about 30-40% of calories from carbohydrate (about 130 g/day) with a significantly lower glycemic load compared to the other diets.  There are some pluses to the “paleo” diet approach as, generally, it is focused on whole foods, eliminates processed foods and refined carbohydrates and is lower in total carbohydrates than the standard diet. 

There are so many versions of the “paleo” diet, and because of this, I believe that it may promote some imbalances - especially for those that focus on the meat-eating aspects of the diet.  If the high animal protein component is not properly balanced with alkaline foods this can promote acidity (not healthy long term, especially for someone with diabetes).  In addition, the high animal protein focused “paleo” approach may promote an imbalanced fat intake – higher saturated/unhealthy omega-6 fats versus healthier monounsaturated and polyunsaturated fats.  Since there is evidence that the type of fat you consume is important for health, I think this an important point especially for diabetics who are at risk for other health conditions such as, cardiovascular disease.  In general, saturated fat is not "bad", but a high intake of animal protein (especially of processed meats, factory farmed animals, red meats) is not necessarily good and saturated fat shouldn’t be a major fat source.  With appropriate modifications, certain aspects (mostly as a lower carbohydrate, low glycemic load diet with a whole foods emphasis) of this approach may be a good option for managing type 2 diabetes.

 There have been a few positive studies in type 2 diabetics using a very low carbohydrate (20-30 g/day), ketogenic type diet .  One study found significantly greater improvements in weight loss, glycemic control, lipids, reduction/elimination of medications (including insulin) compared with a low glycemic diet (55% of calories from carbohydrate), reduced calorie diet.  The low glycemic diet also showed improvements in weight, glycemic control and reductions/eliminations in medications.   I wonder if results would have been better for the low glycemic diet group if the total carbohydrate was lowered… I’m guessing yes.

What about a low glycemic diet for controlling diabetes with diet?

We know that not all carbohydrates are the same – they don’t all have the same effect on blood sugar levels.  A high glycemic load diet promotes insulin resistance and metabolic syndrome and has been linked with increased risk of type 2 diabetes and cardiovascular disease.  A recent two year study in overweight or obese subjects showed that a low glycemic load diet over 2 years reduced weight similarly to a low-fat diet, but also better maintained metabolic rate and resulted in greater reductions in inflammatory markers, insulin resistance, blood pressure, triglycerides and hunger. 

The low carbohydrate studies mentioned above and others indicate that a component of diet linked with greater improvements in glycemic control and other health markers incorporated a lower carbohydrate, low glycemic impact approach.   A low glycemic impact approach should be incorporated into diet plans for managing type 2 diabetes.

Are there health concerns with higher protein or fat intakes when managing type 2 diabetes with diet?

Decline in renal function is a complication seen in diabetics and is due to long-term poor glycemic control (possibly from a high carbohydrate diet!) and not dietary protein intake.  If you are a diabetic with normal renal function, a higher protein intake doesn’t appear to be linked with adverse effects on healthy kidneys. With that said, I do favor a higher fat, moderate protein, lower carbohydrate diet plan for managing type 2 diabetes.

The link between dietary fat and chronic disease is highly debated.  The type of fat you eat seems most important.  In fact, a diet high in refined sugars and high-glycemic carbohydrates appears to not only have a greater negative impact on glycemic control, but also on blood cholesterol and other markers of cardiovascular health compared with dietary fat. 

 

Managing Type 2 Diabetes with Diet: The Bottom Line

Ultimately, you need to personalize your diet to fit you.  Some measures you can use to monitor your progress can include: your weight, % body fat, % lean body mass, waist circumference, your lab values (blood sugar, insulin levels, HbA1c, lipid panel including LDL, HDL particle size, high sensitivity C-reactive protein, blood pressure as well as certain nutrient levels such as, vitamin D, magnesium and fatty acids), appetite and satiety, improvements in other medical conditions.  And, do you feel in better?

  • Start with a lower carbohydrate, low glycemic impact meal plan:

40% of total calories from carbohydrate with emphasis on whole, intact and sprouted grains, non-starchy vegetables, low glycemic whole fruits.  Try to significantly reduce "broken" grains and flours - maintain a low glycemic load diet.

30% of total calories from quality protein (organic, free range poultry, wild fish, pasture raised eggs)

30% of total calories from fat with emphasis on quality olive oil, avocados, unroasted nuts and seeds, wild salmon and sardines and smaller quantities of quality unrefined oils such as, grapeseed oil, coconut oil, organic butter

Including: 5-6 small meals, quality protein or fat with each meal/snack, whole foods based, high fiber (aim for 50 g/day, 25 g from soluble fiber) with a focus on soluble fibers such as, oats beans, fruit, vegetables and nuts.   Make sure you get in adequate daily magnesium from sources such as, almonds, cashews, Brazil nuts, buckwheat, wheat germ.  Include Cassia cinnamon daily - 1tsp./day.

Eliminate refined carbohydrates and sugars, artificial sweeteners, processed foods, trans fats, industrial oils such as, corn and soy and fruit juice or other sweetened beverages.   

An example diabetic diet meal plan for a day might look like this:

AM: Small bowl cooked steel cut or old fashioned oats, raw walnuts, 2 Tbsp fresh ground flax seed, 1 tsp. cinnamon, palm-full of blueberries, unsweetened almond or coconut milk, unsweetened almond butter.  Omega-3 rich, organic, pasture raised boiled egg. Unsweetened green tea 

Snack: Almonds. Palm-full of strawberries

Lunch: Salad: organic, free range grilled/baked chicken breast; thighs or baked tempeh with chickpeas/other beans (palm-sized serving), chopped celery, tomatoes, avocado, olives, radish, green onions, broccoli, beets (palm-sized serving), plus any other non starchy veggies. Dress with quality olive oil, vinegar, lemon or lime juice and dash of  of sea salt and pepper.  Serve over mixed greens or baby spinach.  

Snack: Avocado w/ lemon.  Cashews. Hummus w/ nonstarchy vegetables

PM: Grilled wild salmon drizzled with olive oil, quinoa (palm-sized serving), ½ medium sweet potato mixed in with quinoa, broccoli and onions sautéed in coconut oil, green salad.

Snack: Few cubes (palm-sized serving) of organic, natural cheeses

Here are additional diabetes diet plans and recipes (use promotional code "Vitality 1" on the "Sign Up Now" page for 15% off your subscription) from the experts at MyFoodMyHealth.

  • Consider a lower carbohydrate diet  (<130 g/day) in combination with a low glycemic impact, whole foods approach.  

To do this you will need to further restrict grains, starchy vegetables, fruits and legumes and increase your healthy fat sources. Be aware of possible nutritional inadequacies with a lower carbohydrate diet or when eliminating certain food groups (ie make sure you take a high quality professional line multivitamin/mineral with adequate calcium and vitamin D, get adequate fiber).

  • Consider a very low carbohydrate (20-30 g/day) ketogenic type diet under medical supervision.
  • Nutritional supplementation and managing type 2 diabetes with diet:

Its best to use testing to guide supplementation. Antioxidants and micronutrients should be adjunctive therapy to optimal nutrition. In general, don’t take high doses of only one or two vitamins or minerals - remember that nutrients work together - and for some populations this has shown to be harmful.  Start with a high quality, professional line multivitamin with chelated minerals to make sure that you establish a “good base” first.   

These supplements have been linked with improvements in blood sugar control in diabetics by targeting underlying root imbalances contributing to the development and persistence of the condition.  Consider trying them one at a time and monitor the effects under a qualified practitioner.

Chromium picolinate  (start with 100mcg twice daily, use only if no renal problems and you are not pregnant or lactating)  Also, 1 TBSP of Brewers yeast = 60 mcg chromium.

Chelated (glycinate or citrate) magnesium  (start with 300 mg/day)

Trial a quality soluble fiber supplement (psyllium, guar gum) or pre-meal glucomannan powder (konjac or “super fiber”) (Take any medications one hour prior or 4 hours after using these supplements as these fibers can interfere with drug absorption)

Other possibilities may include: alpha lipoic acid for neuropathy, coenzyme Q10 if on statin drugs

Population research shows that people with lower vitamin D levels have a significantly higher risk of type 2 diabetes compared to people with higher vitamin D levels.  Supplement with vitamin D3 based on serum levels and aim for the optimal range of 50-70ng/dL.


This is a general discussion about managing type 2 diabetes with diet.  Exercise (including interval and resistance training, yoga), adequate sleep and stress management are also important factors to consider when managing this condition.


Home > Diabetes and Diet > Managing Type 2 Diabetes with Diet 


10/2013

Some references:   Nielson, J. et al. Low-carbohydrate diet in type 2 diabetes: stable improvement of bodyweight and glycemic control during 44 months follow-up. Nutrition and Metabolism 2008 5(14): doi:10.1186/1743-7075-5-14.;   Westman, E. et al. The effect of a low-carbohydrate, ketogenic diet versus a low-glycemic index diet on glycemic control in type 2 diabetes mellitus. Nutrition & Metabolism, 2008, 5(36): doi:10.1186/1743-7075-5-36.;   Surender, A. et al. The case for low carbohydrate diets in diabetes management.  Nutrition and Metabolism 2005 2(16): doi:10.1186/1743-7075-2-16.;   Jacob, A. Low-Carb Diets — Research Shows They May Be More Beneficial Than Other Dietary Patterns.
Today’s Dietitian,
2013, 15(8):12.;   Hite, A. et al. Low-Carbohydrate Diet Review: Shifting the Paradigm. Nutrition in Clinical Practice, 2011 26(3): 300-8.;   Kirk, J. et al. Restricted-Carbohydrate Diets in Patients with Type 2 Diabetes: A Meta-Analysis. JADA, 2008, 108(1):91-100.;   IFM, Clinical nutrition: a functional approach, 2004;    IFM Textbook of Functional Medicine, 2010;  Natural Medicines Comprehensive Database

 

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