kelingwang/causation_strength_rating huggingface dataset:
Individuals with type 1 or type 2 diabetes taking insulin at mealtime should be offered comprehensive and ongoing education about nutrition content and the need to couple insulin administration with carbohydrate intake.
For people whose meal schedule or carbohydrate consumption is variable, regular education to increase understanding of the relationship between carbohydrate intake and insulin needs is important.
In addition, education on using insulin-to-carbohydrate ratios for meal planning can assist individuals with effectively modifying insulin dosing from meal to meal to improve glycemic management (104,178,206–208).
Studies have shown that dietary fat and protein can impact early and delayed postprandial glycemia (209–212), and it appears to have a dose-dependent response (213–216).
Results from high-fat, high-protein meal studies highlight the need for additional insulin to cover these meals; however, more studies are needed to determine the optimal insulin dose and delivery strategy.
The results from these studies also point to individual differences in postprandial glycemic response; therefore, a cautious approach to increasing insulin doses for high-fat and/or high-protein mixed meals is recommended to address delayed hyperglycemia that may occur after eating (73,217,218).
If using an insulin pump, a split bolus feature (part of the bolus delivered immediately, the remainder over a programmed duration of time) may provide better insulin coverage for high-fat and/or high-protein mixed meals (210,219).
The effectiveness of insulin dosing decisions should be confirmed with a structured approach to blood glucose monitoring or CGM to evaluate individual responses and guide insulin dose adjustments.
Checking glucose 3 h after eating may help to determine if additional insulin adjustments are required (i.e., increasing or stopping bolus) (210,219,220).
Adjusting insulin doses to account for high-fat and/or high-protein meals requires determination of anticipated nutrient intake to calculate the mealtime dose.
Food literacy, numeracy, interest, and capability should be evaluated (73).
For individuals on a fixed daily insulin schedule, meal planning should emphasize a relatively fixed carbohydrate consumption pattern with respect to both time and amount while considering insulin action.
Attention to resultant hunger and satiety cues will also help with nutrient modifications throughout the day (73,221).
Commercially available automated insulin delivery systems still require basic diabetes management skills, including carbohydrate counting and understanding of the impact of protein and fat on postprandial glucose response (222).
There is no evidence that adjusting the daily level of protein intake (typically 1–1.5 g/kg body weight/day or 15–20% of total calories) will improve health, and research is inconclusive regarding the ideal amount of dietary protein to optimize either glycemic management or CVD risk (203,223).
Therefore, protein intake goals should be individualized based on current eating patterns.
Some research has found successful management of type 2 diabetes with meal plans including slightly higher levels of protein (20–30%), which may contribute to increased satiety (224).
Historically, low-protein eating plans were advised for individuals with diabetic kidney disease (DKD) (with albuminuria and/or reduced estimated glomerular filtration rate); however, current evidence does not suggest that people with DKD need to restrict protein to less than the generally recommended protein intake (73).
Reducing the amount of dietary protein below the recommended daily allowance of 0.8 g/kg is not recommended because it does not alter glycemic measures, cardiovascular risk measures, or the rate at which glomerular filtration rate declines and may increase risk for malnutrition (225–227).
Strong evidence suggests higher plant protein intake and replacement of animal protein with plant protein is associated with lower risk of all-cause and cardiovascular mortality in the Women�s Health Initiative cohort study (228).
A meta-analysis of 13 RCTs showed replacing animal with plant proteins leads to small improvements in A1C and fasting glucose in individuals with type 2 diabetes (229).
Plant proteins are lower in saturated fat and support planetary health (230).
In addition to annually, there are critical time points when the need for DSMES should be evaluated by the health care professional and/or interprofessional team, with referrals made as needed (2): At diagnosis; When not meeting treatment goals; When complicating factors (e.g., health conditions, physical limitations, emotional factors, or basic living needs) that influence self-management develop; When transitions in life and care occur.
Evidence suggests that there is not an optimal percentage of calories from fat for people with or at risk for diabetes and that macronutrient distribution should be individualized according to the individual�s eating patterns, preferences, and metabolic goals (73).
The type of fats consumed is more important than total amount of fat when looking at metabolic goals and CVD risk, and it is recommended that the percentage of total calories from saturated fats should be limited (98,129,231–233).
Multiple RCTs including people with type 2 diabetes have reported that a Mediterranean eating pattern (95,129,234–239) can improve both glycemic management and blood lipids.
The Mediterranean eating pattern is based on the traditional eating habits in the countries bordering the Mediterranean Sea.
Although eating styles vary by country or culture, they share a number of common features, including consumption of fresh fruits and vegetables, whole grains, beans, and nuts/seeds; olive oil as the primary fat source; low to moderate amounts of fish, eggs, and poultry; and limited added sugars, sugary beverages, sodium, highly processed foods, refined carbohydrates, saturated fats, and fatty or processed meats.
Evidence does not conclusively support recommending n-3 (eicosapentaenoic acid and docosahexaenoic acid) supplements for all people with diabetes for the prevention or treatment of cardiovascular events (73,240,241).
In individuals with type 2 diabetes, two systematic reviews with n-3 and n-6 fatty acids concluded that the dietary supplements did not improve glycemic management (203,242).
In the ASCEND (A Study of Cardiovascular Events iN Diabetes) trial, when compared with placebo, supplementation with n-3 fatty acids at a dose of 1 g/day did not lead to cardiovascular benefit in people with diabetes without evidence of CVD (243).
However, results from the Reduction of Cardiovascular Events With Icosapent Ethyl-Intervention Trial (REDUCE-IT) found that supplementation with 4 g/day of pure eicosapentaenoic acid significantly lowered the risk of adverse cardiovascular events.
This trial of 8,179 participants, in which over 50% had diabetes, found a 5% absolute reduction in cardiovascular events for individuals with established atherosclerotic CVD taking a preexisting statin with residual hypertriglyceridemia (135–499 mg/dL [1.52–5.63 mmol/L]) (244).
See Section 10, �Cardiovascular Disease and Risk Management,� for more information.
People with diabetes should be advised to follow the guidelines for the general population for the recommended intakes of saturated fat, dietary cholesterol, and trans fat (98).
Trans fats should be avoided.
In addition, as saturated fats are progressively decreased in the diet, they should be replaced with unsaturated fats and not with refined carbohydrates (238).
Despite lack of evidence of benefit from dietary supplements, consumers continue to take them.
Estimates show that up to 59% of people with diabetes in the U.S. use supplements (250).
Without underlying deficiency, there is no benefit from herbal or nonherbal (i.e., vitamin or mineral) supplementation for people with diabetes (73,251).
Federal law in the U.S. broadly defines dietary supplements as having one or more dietary ingredients, including vitamins, minerals, herbs or other botanicals, amino acids, enzymes, tissues from organs or glands, or extracts of these (252).
Routine antioxidant supplementation (such as vitamins E and C) is not recommended due to lack of evidence of efficacy and concern related to long-term safety.
In addition, there is insufficient evidence to support the routine use of herbal supplements and micronutrients, such as cinnamon (254), curcumin, vitamin D (255), aloe vera, or chromium, to improve glycemia in people with diabetes (73,256).
Although the Vitamin D and Type 2 Diabetes Study (D2d) prospective RCT and Diabetes Prevention and Active Vitamin D (DPVD) showed no significant benefit of vitamin D versus placebo on the progression to type 2 diabetes in individuals at high risk (257,258), post hoc analyses and meta-analyses suggest a potential benefit in specific populations (257,259–261).
Further research is needed to define individual characteristics and clinical indicators where vitamin D supplementation may be of benefit.
Metformin is associated with vitamin B12 deficiency per a report from the Diabetes Prevention Program Outcomes Study (DPPOS), which suggests that periodic testing of vitamin B12 levels should be considered in people taking metformin, particularly in those with anemia or peripheral neuropathy (262,263) (see Section 9, �Pharmacologic Approaches to Glycemic Treatment�).
Consumers can consult the U.S. Food and Drug Administration (FDA) Dietary Supplement Ingredient Directory to locate information about ingredients used in dietary supplements and any action taken by the agency with regard to that ingredient (264).
For special populations, including pregnant or lactating individuals, older adults, vegetarians, and people following very-low-calorie or low-carbohydrate diets, a multivitamin may be necessary (265).
Based on the 2022 U.S. Preventative Services Task Force statement, the harms of �-carotene outweigh the benefits for the prevention of CVD or cancer.
�-Carotene was associated with increased lung cancer and cardiovascular mortality risk (253).
Moderate alcohol intake ingested with food does not have major detrimental effects on long-term blood glucose management in people with diabetes.
Risks associated with alcohol consumption include hypoglycemia and/or delayed hypoglycemia (particularly for those using insulin or insulin secretagogue therapies), weight gain, and hyperglycemia (for those consuming excessive amounts) (73,256).
The available evidence does not support recommending alcohol consumption in people who do not currently drink (266).
To reduce risk of alcohol-related harms, adults can choose not to drink or to drink in moderation by limiting intake to =2 drinks a day for men or =1 drink a day for women (one drink is equal to a 12-oz beer, a 5-oz glass of wine, or 1.5 oz of distilled spirits) (266).
People with diabetes should be educated about these risks and encouraged to monitor glucose frequently after drinking alcohol to minimize such risks.
People with diabetes can follow the same guidelines as those without diabetes consistent with Dietary Guidelines for Americans, 2020–2025 (98).
There is growing evidence for psychoeducational interventions that may increase knowledge about alcohol use and diabetes, may enhance perceived risks, and may reduce alcohol use among young people with type 1 diabetes (267).
As for the general population, people with diabetes are advised to limit their sodium consumption to <2,300 mg/day (73).
Restriction to <1,500 mg, even for those with hypertension, is generally not recommended (245–247).
Sodium recommendations should take into account palatability, availability, affordability, and the difficulty of achieving low-sodium recommendations in a nutritionally adequate eating plan (248,249).
The FDA has approved many nonnutritive sweeteners (NNS) for consumption by the general public, including people with diabetes (73,268).
However, the safety and role of NNS continue to be sources of concern and confusion for the public (269).
This confusion has been heightened with the World Health Organization�s conditional recommendation (270) against NNS for weight management, the Cleveland Clinic study on erythritol and its relationship to CVD (271), and the International Agency for Research on Cancer classifying aspartame as a possible carcinogen to humans (272).
It should be noted the systematic analysis that informed the World Health Organization recommendation excluded individuals with diabetes.
In an editorial from the Journal of Clinical Investigation, Nobs and Elinav (273) from the Weizmann Institute described the impact these recent studies have had on the public perception of safety of NNS: The burden of proof has shifted from a need to prove that NNS are unsafe to a necessity of understanding their potential scope of effects on humans in order to optimize their recommended use by populations at risk.
Despite FDA approval and generally recognized as safe (GRAS) status for NNS, as well as established acceptable daily intake (ADI), questions remain.
Implementation and interpretation of human NNS studies are inherently challenging.
Each of the sweeteners are their own distinct compounds with different molecular structures, although they are often considered together in studies.
Issues of duration of exposure (short or long), different physical forms (packets/powder or in beverages), cardiometabolic health of the host, personalized individual response, presence of other nutrient components, the emerging evidence about the microbiome, and limited RCTs complicate the science (273).
For some people with diabetes who are accustomed to regularly consuming sugar-sweetened products, NNS (containing few or no calories) may be an acceptable substitute for nutritive sweeteners (those containing calories, such as sugar, honey, and agave syrup) when consumed in moderation (274,275).
NNS do not appear to have a significant effect on glycemic management (104,276,277), and they can reduce overall calorie and carbohydrate intake (104,274) as long as individuals are not compensating with additional calories from other food sources (73,278).
There is mixed evidence from systematic reviews and meta-analyses for NNS use with regard to weight management, with some finding benefit in weight loss (279–281) while other research suggests an association with weight gain (282,283).
This may be explained by reverse causality and residual confounding variables (283).
The addition of NNS to eating plans poses no benefit for weight loss or reduced weight gain without energy restriction (284).
In a recent systematic review and meta-analysis using low-calorie and no-calorie sweetened beverages as an intended substitute for sugar-sweetened beverages, a small improvement in body weight and cardiometabolic risk factors was seen without evidence of harm and had a direction of benefit similar to that seen with water.
Health care professionals should continue to recommend water, but people with overweight or obesity and diabetes may also have a variety of no-calorie or low-calorie sweetened products so that they do not feel deprived (285).
Health care professionals should continue to recommend reductions in sugar intake and calories with or without the use of NNS.
Assuring people with diabetes that NNS have undergone extensive safety evaluation by regulatory agencies and are continually monitored can allay unnecessary concern for harm.
Health care professionals can regularly assess individual use of NNS based on the acceptable daily intake (amount of a substance considered safe to consume each day over a person�s life) and recommend moderation.
See the chart from the FDA on safe levels of sweeteners found at fda.gov/food/food-additives-petitions/aspartame-and-other-sweeteners-food.
Exercise and Youth
Youth with diabetes or prediabetes should be encouraged to engage in regular physical activity, including at least 60 min of moderate to vigorous aerobic activity every day and muscle- and bone-strengthening activities at least 3 days per week (299).
In general, youth with type 1 diabetes benefit from being physically active, and meta-analyses have demonstrated a significant association between physical activity and lower A1C (300).
Thus, an active lifestyle should be recommended to all (301).
Youth with type 1 diabetes who engage in more physical activity may have better health outcomes and health-related quality of life (302,303).
See Section 14, �Children and Adolescents,� for details.
Physical activity is a general term that includes all movement that increases energy use and is an important part of the diabetes management plan.
Exercise is a more specific form of physical activity that is structured and designed to improve physical fitness.
Both physical activity and exercise are important.
Exercise has been shown to improve blood glucose levels, reduce cardiovascular risk factors, contribute to weight loss, and improve well-being (286).
Physical activity is as important for those with type 1 diabetes as it is for the general population, but its specific role in the prevention of diabetes complications and the management of blood glucose is not as clear as it is for those with type 2 diabetes.
Many individuals with type 2 diabetes do not meet the recommended exercise level per week (150 min).
Objective measurement by accelerometer in 871 individuals with type 2 diabetes showed that 44.2%, 42.6%, and 65.1% of White, African American, and Hispanic individuals, respectively, met the recommended threshold of exercise (287).
An RCT in 1,366 individuals with prediabetes combined a physical activity intervention with text messaging and telephone support, which showed improvement in daily step count at 12 months compared with the control group.
Unfortunately, this was not sustained at 48 months (288).
Another RCT, including 324 individuals with prediabetes, showed increased physical activity at 8 weeks with supportive text messages, but by 12 weeks there was no difference between groups (289).
It is important for diabetes care management teams to understand the difficulty that many people have reaching recommended treatment goals and to identify individualized approaches to improve goal achievement, which may need to change over time.
Moderate to high volumes of aerobic activity are associated with substantially lower cardiovascular and overall mortality risks in both type 1 and type 2 diabetes (290).
A prospective observational study of adults with type 1 diabetes suggested that higher amounts of physical activity led to reduced cardiovascular mortality after a mean follow-up time of 11.4 years for people with and without chronic kidney disease (291).
Additionally, structured exercise interventions of at least 8 weeks� duration have been shown to lower A1C by an average of 0.66% in people with type 2 diabetes, even without a significant change in BMI (292).
There are also considerable data for the health benefits (e.g., increased cardiovascular fitness, greater muscle strength, improved insulin sensitivity) of regular exercise for those with type 1 diabetes (293).
Exercise training in type 1 diabetes may also improve several important markers such as triglyceride level, LDL cholesterol, waist circumference, and body mass (294).
In adults with type 2 diabetes, higher levels of exercise intensity are associated with greater improvements in A1C and in cardiorespiratory fitness (295); sustained improvements in cardiorespiratory fitness and weight loss have also been associated with a lower risk of heart failure (258).
Other benefits include slowing the decline in mobility among overweight people with diabetes (296).
The ADA position statement �Physical Activity/Exercise and Diabetes� reviews the evidence for the benefits of exercise in people with type 1 and type 2 diabetes and offers specific recommendations (297).
Increased physical activity (soccer training) has also been shown to be beneficial for improving overall fitness in Latino men with obesity, demonstrating feasible methods to increase physical activity in this population (298).
Physical activity and exercise should be recommended and prescribed to all individuals who are at risk for or with diabetes as part of management of glycemia and overall health.
Specific recommendations and precautions will vary by the type of diabetes, age, activity, and presence of diabetes-related health complications.
Recommendations should be tailored to meet the specific needs of each individual (297).
For all people with diabetes, evaluate baseline physical activity and time spent in sedentary behavior (quiet sitting, lying, and leaning).
For people who do not meet activity guidelines, encourage an increase in physical activity (walking, yoga, housework, gardening, swimming, and dancing) above baseline (304).
Health care professionals should counsel people with diabetes to engage in aerobic and resistance exercise regularly (240).
Aerobic activity bouts should last at least 10 min, with the goal of ~30 min/day or more most days of the week for adults with type 2 diabetes.
Daily exercise, or at least not allowing more than 2 days to elapse between exercise sessions, is recommended to decrease insulin resistance, regardless of diabetes type (305,306).
A study in adults with type 1 diabetes found a dose-response inverse relationship between self-reported bouts of physical activity per week and A1C, BMI, hypertension, dyslipidemia, and diabetes-related complications such as hypoglycemia, diabetic ketoacidosis, retinopathy, and microalbuminuria (307).
Over time, activities should progress in intensity, frequency, and/or duration to at least 150 min/week of moderate-intensity exercise.
Adults able to run at 6 miles/h (9.7 km/h) for at least 25 min can benefit sufficiently from shorter durations of vigorous-intensity activity or interval training (75 min/week) (297).
Many adults, including most with type 2 diabetes, may be unable or unwilling to participate in such intense exercise and should engage in moderate exercise for the recommended duration.
Physical Activity and Glycemic Management
Clinical trials have provided strong evidence for the A1C-lowering value of resistance training in older adults with type 2 diabetes (297) and for an additive benefit of combined aerobic and resistance exercise in adults with type 2 diabetes (319).
If not contraindicated, people with type 2 diabetes should be encouraged to do at least two weekly sessions of resistance exercise (free weights, machines, elastic bands, or body weight as resistance), with each session consisting of at least one set (group of consecutive repetitive exercise motions) of five or more different resistance exercises involving the large muscle groups (320).
For people with type 1 diabetes, although exercise, in general, is associated with improvement in disease status, care needs to be taken in titrating exercise with respect to glycemic management.
Each individual with type 1 diabetes has a variable glycemic response to exercise.
This variability should be taken into consideration when recommending the type and duration of exercise for a given individual (293).
Individuals of childbearing potential with preexisting diabetes, particularly type 2 diabetes, and those at risk for or presenting with gestational diabetes mellitus should be advised to engage in regular moderate physical activity prior to and during their pregnancies as tolerated (297).
High-Intensity Interval Training
High-intensity interval training (HIIT) is a plan that involves aerobic training done between 65% and 90% VO2peak or 75% and 95% heart rate peak for 10 s to 4 min with 12 s to 5 min of active or passive recovery.
HIIT has gained attention as a potentially time-efficient modality that can elicit significant physiological and metabolic adaptations for individuals with type 1 and type 2 diabetes (321,322).
Higher intensities of aerobic training are generally considered superior to low-intensity training (323).
HIIT showed reductions in A1C and BMI and improvement in fitness levels in individuals with type 2 diabetes.
Because HIIT can lead to transient increases in post-exercise hyperglycemia, individuals with type 2 diabetes are encouraged to monitor blood glucose when starting (320).