EN    EN EN 
 
EN    EN  COMMISSION OF THE E UROPEAN COMMUNITIES 
Brussels, 10.7.2008 
SEC(2008) 2294 
COMMISSION STAFF WORKING DOCUMENT 
 
SUMMARY OF MAIN POINTS OF SC IENTIFIC BASIS OF THE DIETARY 
RECOMMENDATION FOR DIABETICS 
 
EN 2   EN SUMMARY OF MAIN POINTS OF SC IENTIFIC BASIS OF THE DIETARY 
RECOMMENDATION FOR DIABETICS  
 
This document's aim is to contribute to comprehension of document COM(2008)392  
In 2004 a group coordinated by Mannii on behalf of the Diabetes  and Nutrition Study Group 
of the European Association for the Study of Diabetes (DNSG of the EASD)  reviewed the 
evidence for nutritional approaches to the trea tment and prevention of diabetes mellitus and 
made recommendations based on evidence for di etary advice to people with diabetes. The 
strength of evidence for each of the recommendations was graded according to the nature of the studies on which they were based. Below is a summary of some of the main points of the 
review. 
Energy balance and body weight 
The review concluded that those who are overweight (BMI above 25 kg/m
2 should lose 
weight so that the BMI moves towards th e recommended range of between 18.5 and 25 
kg/m2. The prevention of weight gain and the main tenance of a desirable weight is important. 
While it may not always be possible for individua ls to achieve or maintain a desirable BMI, 
modest weight loss (under 10% body weight) improves insulin sensitivity and glucose tolerance and reduces lipid levels and blood pressure. 
Dietary fats 
People with diabetes mellitus have an increased  risk of cardiovascular disease, which is 
around 2-4 times greater than for people w ithout diabetes. The evidence supporting the 
recommendations for dietary fat intake is mainly based on studies involving non-diabetic 
subjects. There are no controlle d dietary intervention studies  of sufficient power among 
people with diabetes. There are some studies on people with diabetes comparing the effects of 
diets with different fatty acid composition that support the evidence in re spect of non-diabetic 
subjects. It is recommended that total fat intake  should not exceed 35 % of total energy due 
to the increased body weight of people on high-fat diets. In addition, high fat intakes may 
have adverse effects on insulin sensitivity.  
The evidence in the case of non-diabetic subjects that exchange of saturated fatty acids  with 
unsaturated fatty acids or car bohydrates reduces plasma LDL cholesterol is supported by a 
few controlled studies on subjects with diabetes . In contrast to other saturated fatty acids, 
though, stearic acid does not increa se cholesterol. The consumption of saturated fatty acids 
and trans fatty acids causes an increase in blood  insulin levels. In two prospective studies on 
subjects with diabetes, the ratio of polyunsaturat ed to saturated fatty acids in the diet was 
significantly associated with coronary heart disease events. The recommendation is that saturated and trans fatty aci ds should provide less th an 10% of total energy. 
Regarding monounsaturated fatty acids  (MUFA), Mann notes contro lled studies, mainly on 
subjects with diabetes whose weight is within the normal ra nge, indicating that serum lipid 
levels may be improved by the substitution of a certain amount of MUFA for carbohydrates. The effects were seen when the substituted carbohydrates were mainly starch-rich foods with a low content of dietary fibre and high glycaem ic index. The dietary re commendation is that 
oils rich in MUFA are useful fat sources and, depending on individual preferences, may 
provide 10-20% of total energy, pr ovided the total fat content of the diet is less than 35% total 
energy. 
 
EN 3   EN The replacement of satu rated fatty acids with polyunsaturated fatty acids  has positive 
effects on serum lipid levels, lipoprotein concentration and composition and insulin sensitivity. The effects of m ono- and polyunsaturated fatty aci ds on blood glucose and blood 
lipid levels appear similar. A high polyunsaturated to satura ted fatty acid ratio has been 
associated with a low risk of fatal cardiovasc ular events in people with diabetes. It is 
recommended that polyunsaturated fatty acid intake should not exceed 10% of total energy. 
With respect to n-3 polyunsaturated fatty acids there are no published controlled studies to 
suggest that supplementation with n-3 fatty acids improves insulin sensitivity. There are 
insufficient data to make specific recommendations  on the optimal ratio of  n-3:n-6 fatty acids. 
However, in line with the recommendations for the general population, it is recommended that 
dietary intake of n-3 fatty acids  be encouraged through consump tion of fish and plant sources 
of n-3 fatty acids. 
On the basis of data relating to non-diabetic  people and people with type 1 diabetes, it is 
recommended to restrict  dietary intake of cholesterol,  as increased plasma cholesterol levels 
are associated with increasing intake of cholesterol. The recommendation is that daily intake of cholesterol should not exceed 300mg. 
Carbohydrates 
The recommended range of carbohydrate  intake of 45-60% of total is based on the limits for 
the intake of fats and protein. The review notes  a meta-analysis compar ing the effects of high-
carbohydrate diets with diets highe r in MUFA and lower in car bohydrates. It concluded that 
the long-term effects on glycaemic control of the different diets were comparable. In some of 
the high-carbohydrate studies there were untoward effects on the fasting triglyceride levels 
which can be avoided if the carbohydrate foods are rich in dietary fi bre and/or have a low 
glycaemic index. The review notes that when  choosing carbohydrate-c ontaining foods their 
effect on insulin sensitivity, serum lipids and energy balance should be considered and that 
people with diabetes should regularly consum e vegetables, legumes, intact fruits and 
wholegrain cereals. 
The review notes that controlled studies have indicated that increased intake of dietary fibre  
is associated with improved blood glucose levels . Ideally the intake of dietary fibre should be 
40g/day or more, of which half should be soluble fibre. In addition, several but not all studies 
of diets rich in soluble fibre have found an association between high-fibre diets and lower 
levels of total and LDL choleste rol. The review recommends th at people with diabetes should 
consume foods naturally rich in dietary fibre and that the daily intake should ideally be more 
than 40g. It suggests that daily c onsumption of at least five serv ings of fibre-rich vegetables 
or fruit and at least four servings of legu mes each week can help to provide the minimum 
recommended intake of fibre, whilst cereal -based foods should wherever possible be 
wholegrain. 
The glycaemic index  (GI) was proposed in the early 19 80s as a method to guide food 
selection. A meta-analysis of controlled dietary interven tion studies comparing diets 
containing high GI and low GI foods noted an improvement in  mean blood glucose control. 
The effect of the GI of foods on blood glucose is independent of the ef fects of other dietary 
interventions. The review makes certain caveats about the use of GI for th e selection of foods 
but concludes that carbohydrate-ri ch, low GI foods are suitable  as carbohydrate-rich choices 
provided other attributes of  the foods are appropriate. 
 
EN 4   EN Regarding sucrose , the review notes that in the 1980s several random ised controlled trails 
demonstrated no adverse effects on glycaemic control, lipids and lipoproteins when diets containing small amounts of sucrose were compar ed with “sucrose-free” diets. There are no 
studies available to make specific recommendati ons for the maximum intake of sucrose or 
free sugars by people with diabetes. The recomm endation of limiting intake to less than 10% 
of total energy is based on experts' r ecommendations for the general population. 
Protein 
The review makes the following recommendati ons in relation to protein based on the 
available evidence. In people w ith diabetes with no evidence of nephropathy, protein intake 
may provide 10-20% of total energy; in peopl e with type 1 diabetes with established 
nephropathy, protein intake s hould be at the lower end of the acceptable range, which is 
around 0.8g/kg normal body weight per day. 
Antioxidant nutrients, vitamins, minerals and trace elements 
Evidence in relation to non-diabetic people sugges ts that a range of antioxidant nutrients, 
vitamins , and foods rich in them protect against cardiovascular disease.  Short-term studies 
involving the consumption of foods rich in these nutrients and supplementation studies 
confirm that markers of oxidative stress can be  favourably influenced by substantial intakes. 
However, studies with clinical  endpoints, principally involvi ng non-diabetic people, have not 
demonstrated beneficial effects. The group re commended people with di abetes to eat foods 
rich in such nutrients but did not recommend supplements. 
Moderate dietary sodium  restriction produces a substan tial reduction in systolic blood 
pressure in mildly hypertensive people with type 2 diabetes. It is recommended that, as for the general population, people with diabetes should  restrict their daily salt intake to under 6g. 
The review noted that there is evidence that so me people with diabetes have low levels of 
circulating magnesium  and that magnesium depletion of muscle and bone has been observed 
and linked to retinopathy and polyneuropathy. In addition, it has been suggested that there is a 
role for magnesium supplementation in halting the progression of thes e conditions. However, 
the group concluded that confirma tion of the observations would need to be available before 
firm recommendations could be made. 
The review notes that low levels of zinc and chromium and high levels of copper have been 
reported in people with diabetes but concluded that there was no evidence to suggest that these observations should influence nutritional dietary recommendations. 
Alcohol 
Moderate amounts of alcohol may be associated with improved insulin sensitivity and, in non-
diabetic subjects, is linked to re duced risk of cardiovascular disease. However, alcohol can be 
an important energy source and can also be asso ciated with ra ised levels of blood pressure, 
increased triglycerides and an increased risk  of hypoglycaemia. There are no conclusive data 
on an appropriate upper limit of alcohol intake for people with diabetes, so the 
recommendation is based on what is suggested for the general population – a moderate intake 
(up to 10g/day for women and 20g/day for men). 
 
EN 5   EN The above summary reflects the conclusions included in the review by Mann, although it 
should be noted that there is no evidence of ar guments contradicting their main conclusions 
with regard to dietary advice. The technical review by Franz that formed the basis of the 
American Diabetes Association position statementvi draws similar conclusions. 
 
EN 6   EN REFERENCES  
ii. Mann, J.I. et al . Evidence-based nutritional appr oaches to the treatment and 
prevention of diabetes mellitus. Nutrition, Metabolism, and Cardiovascular Diseases 
(2004) 14: 373-394. 
vi. American Diabetes Association. Ev idence-based nutrition principles and 
recommendations for the treatment and prevention of diabetes and related 
complications (Position statement) . Diabetes Care, 2002, 25: S50-S60.