Carbohydrate and Type Diabetes

The recommended intake of carbohydrate for people with diabetes is 45% to 60% of total energy intake (Table 2). Provided that foods rich in fiber and with low-glycemic index predominate, there are no known deleterious effects with this range of carbohydrate intake. When carbohydrate intakes are at the upper end of the proposed range, restriction of carbohydrate to around 45% of total energy and a partly replacement of carbohydrate by monounsaturated fat may be tried for some patients with unsatisfactory glycemic control. However, there is concern that increased fat intake might promote weight gain and potentially contribute to insulin resistance. The advice for carbohydrate intake should therefore be individualized, based on nutrition assessment, metabolic results and treatment goals, however, there is no justification for the recommendation of very low-carbohydrate diets in persons with diabetes (8,43).

Vegetables, legumes, fresh fruit, and whole-grain cereal-derived foods are the preferred sources of carbohydrate. They are rich in fiber, micronutrients, and vitamins, and help to ensure the recommended intakes of other nutrients. However, many individuals with diabetes do not consume such foods on a regular basis (Fig. 2).

A number of factors influence glycemic response to carbohydrate-containing foods, including the nature of the starch (amylose, amylopectin, resistant starch), the amount of dietary fiber and the type of sugar. Different carbohydrates have different glycemic responses and, clearly, the amount of carbohydrate is one important factor in postprandial glucose levels. However, foods with a low-glycemic index may confer benefits not only for postprandial glycemia in persons with type 2 diabetes, but also for their lipid profile (44-48). Foods with a low-glycemic index (e.g., legumes, pasta, parboiled rice, whole-grain breads, oats, certain raw fruits) should therefore be substituted when possible for those with a high-glycemic index (e.g., mashed potatoes, white rice, white bread and rolls, sugary drinks).

People with diabetes should be encouraged to choose a variety of fiber-containing foods. It has been shown that increased fiber intake results in benefits for glycemic control, hyperinsulinemia and serum lipids (49-51). Dietary fiber intake should ideally be more than 40 g/day, about half of which should be soluble, however, beneficial effects are also obtained with lower, and for some, more acceptable amounts (8). The available evidence from controlled clinical studies demonstrates that moderate intake of dietary sucrose in diets with

TABLE 2 Recommended Nutrient Intakes for Persons with Diabetes

Carbohydrate 45% to 60% total energy/day

Dietary fiber ideally 40g/day (20 g/1000 kcal)

Glycemic index

Sucrose and other free sugars < 10% total energy

Total dietary fat <35% energy/day Saturated fatty acids plus trans-unsaturated fatty acids < 10% total energy

Polyunsaturated fatty acids (n - 6) up to

10% total energy Consider n - 3 unsaturated fatty acids (Cis-) Monounsaturated fatty acids

10% to 20% total energy Cholesterol <300mg/day Protein 10% to 20% total energy/day

Alcohol <20 g/day for men < 10 g/day for women

Antioxidant nutrients, vitamins, minerals, and trace elements Supplements and functional foods

Metabolic characteristics (HbA1c, blood glucose levels, serum lipids) suggest the most appropriate intakes within this range: 225 to 300g in a 2000kcal diet; 170 to 225g in a 1500kcal diet

Foods rich in fiber and with low-glycemic index should be preferred (e.g., legumes, vegetables, fresh fruit, whole-grain cereals, parboiled rice, pasta)

Naturally occurring foods rich in dietary fiber are encouraged (e.g., 5 servings of fiber-rich vegetables or fruits/day, 4 servings of legumes/ week; whenever possible whole-grain cereal-based foods)

Carbohydrate-rich, low-glycemic index foods are a suitable choice provided also other attributes of the foods are appropriate

Monosaccharides and disaccharides added to foods or sugars naturally present in honey, syrup or fruit juice <50g in a 2000kcal diet; <37g in a 1500 kcal diet

< 75 g in a 2000 kcal diet; < 55 g in a 1500 kcal diet

If LDL-cholesterol is elevated <7% total energy (trans-fats are present in several manufactured foods that contain partly hydrogenated fats ! see labeling)

Corn, sunflower, soya bean oils, and seeds

Oily fish (2-3 servings/week) and rapeseed oil, soya bean oil, nuts

Olive oil, rapeseed oil

If LDL-cholesterol is elevated <200mg/day

< 100g in a 2000kcal diet; <75g in a 1500kcal diet (beneficial effects of restricted intakes to 0.8 g/kg desirable body weight have been shown in persons with type 1 diabetes with macroalbuminuria)

Foods naturally rich in dietary antioxidants (tocopherols, carotenoids, vitamin C, flavonoids, polyphenols, phytic acid) should be encouraged

No recommendations are offered. Further research is needed.

an appreciable amount of fiber—with the sucrose displacing other fiber-depleted carbohydrate-containing food—does not worsen glycemic control in persons with diabetes (52-54). Thus, sucrose and other added sugars may be included in moderation in the diets of people with type 2 diabetes, however, the bulk of dietary carbohydrate should be derived from foods with a low-glycemic index and/or rich in fiber. It is of interest that low-glycemic index foods and fiber-rich foods appear to have an effect independent of other attributes; but many highfiber foods do indeed have a low-glycemic index, and vice versa.

Fructose produces a reduction in postprandial glycemia when it replaces sucrose, however, this potential benefit is tempered by the fact that higher amounts of fructose may

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