Volume 13 Number 3, 2000, Page 116
Cycles: Diabetes Nutrition RecommendationsPast, Present, and Future
Madelyn L. Wheeler, MS,
RD, FADA, CDE
"Each thing is of like form from
everlasting and comes around again in its cycle."1
"There have always been recurring cycles of
undress, followed by muffling from shoe-soles to chin."2
Diabetes nutrition recommendations have been no exception to cycles. Throughout
recorded history, they have swung between greater or lesser amounts of a) specific foods,
b) food groups, or c) macronutrients as percentages of calories3,4 (Table 13-13).
As we continually update our scientific bases and as we integrate more and more precise
treatment modalities (self-monitoring of blood glucose, intensive management, pumps),
changes will continue to occur, both in recommendations and in their practical application
(meal planning methods). Will the cycles continue in the new millennium, or will some
event/discovery/scientific breakthrough occur to stop the cyclic nature of the process?
From the beginning of the Egyptian New
Kingdom Period (about 1550 B.C.) to the early 17th century, the few references available
indicated that foods prescribed for individuals with diabetes were high in carbohydrate
but more than likely low in calories. From the early 1800s to the early 1900s,
recommendations for carbohydrates could have been high or low; however, the first adequate
documentation is that for Allen's "starvation" diet (low in carbohydrate and
high in fat when food was "allowed"). With the discovery of insulin in the early
1920s, the cycle again shifted as the recommended percentage of calories from carbohydrate
gradually increased, but this time usually with adequate calories. In the early 1950s, the
American Diabetes Association (ADA), The American Dietetic Association, and the U.S.
Public Health Service joined forces to make nationally applicable recommendations. The
carbohydrate percentages continued to increase, reaching a peak in 1986. In 1994, there
were no recommendations for percentages of calories as carbohydrate or for total fat.
Instead these macronutrients were to be based on nutrition assessment and individualized
These "high" and "low" state ments may be
somewhat mislead ing, as the perception is usually based on previous recommendations. For
example, in 1927, Joslin said of the "optimal" diet (see Table 1) "Many
children and a few adults have not yet reached this quantity of carbohydrate, but I recall
none who are now taking less than 50 grams. Furthermore one can observe a steady increase
in this amount, formerly considered liberal. . . ."
While there's no indication of what we now call "type"
of diabetes, probably the low-calorie effects of any diet before the discovery of insulin
worked to the benefit of the patient.
|Table 1. Nutrition
Recommendations for Diabetes Mellitus Throughout the Ages3-13
||Wheat grains, grapes, honey, berries3,4
||Cereals, fruits, sweet wine3,4
|1797-early 19th century
No plant products except a
small amount of wheat flour
Breakfast: 1 1/2 pts milk, 1/2 pt lime
water, bread and butter.
Noon: Plain bread pudding (blood and
Dinner: fat and rancid old meat and game.
Supper: like breakfast4
||Diluted milk, occasionally boiled with white bread/barley4
|End of 19th century
Rice, oatmeal, potato,
legume, or porridge diets (or "cures," as they were commonly called)4
||Low (includes fasting)
||Allen's "starvation" diet5
||Joslin's "weighed" diets6
||1,600 cal/day=3 slices whole wheat bread, saucer of
cereal, 3 oranges, 4 portions of 5% vegetables,a 1/4 pt milk, 1/4 pt cream, 1
egg, 2 moderate portions of meat, 1 oz butter7
||1,700 cal/day=1 pt whole milk, A vegetablesb as
desired, 1B vegetable serving,c 3 fruit servings, 8 bread servings, 7 meat
servings, 3 fat servings. Note: Serving = exchanges8,9
||45% or more
||American Diabetes Association10
-the difference -<10% as
||American Diabetes Association11
||total fat <30%
||American Diabetes Association12
||<10% from saturated fat
||American Diabetes Association13
a, 5% vegetables were
those vegetables containing 5% carbohydrate (or 1 g of carbohydrate per ounce). Examples
are broccoli, lettuce, tomatoes.
b, A vegetables were those vegetables containing
little carbohydrate, protein, or calories. Examples are broccoli, lettuce, tomatoes.
c, B vegetables were those vegetables containing
about 7 g carbohydrate, 2 g protein, and 35 calories per serving. Examples are carrots,
onion, and winter squash.
General nutrition recommendations, however, are only one
part of the story. They somehow need to be translated into meaningful terms for
individuals: what and how much food to eat. To do this, we have focused on the chemical
composition of foods and from this designed meal planning methods.
Nutrient Analysis: The Essential "Tool" for
Translating Guidelines Into Food Recommendations
There are several significant events in the history of nutrient analysis. The
first was the development, in the 1860s, of suitable methods for determining the chemical
composition of human foods. In 1896, the first United States Department of Agriculture
(USDA) analysis of more than 2,500 American food products was published, followed in the
late 1920s with food composition tables for beef, fresh fruits, and vegetables.14 These
food composition tables allowed the "weighed" diets of Joslin to be so
successful. The USDA tables have been updated and expanded continually, providing the
foundation for most food composition databases in the public and private sectors. The
latest update is Release 13 of the USDA Nutrient Database for Standard Reference in
November 1999,15 providing 6,210 food items and up to 82 food components.
Another significant event was the 1993
requirement for the food label nutrition facts panel (with standard serving sizes) on all
processed foods, as well as fresh fruit, vegetables, and seafoods sold in the United
States. For the first time, this allowed people to monitor nutrient composition of
individual foods easily.
Finally, the advent of and expansion of
nutrient analysis software programs has allowed us to speedily integrate and manipulate
databases and other information in more and more sophisticated ways to meet specific needs
(e.g., analyze nutrient data, provide meal planning, and track health and exercise).16
Meal Planning: Translating Nutrition Recommendations
Into Practical Approaches to Eating and Managing Diabetes
A number of meal planning methods have been identified since the early 20th
century,17,18 all based more or less on the chemical composition analysis of
foods. For example:
The "weighed" diet has been used since the 1920s and
was based on the amount of carbohydrate per ounce in foods.
Carbohydrate counting as a meal-planning resource has been used
at some centers in the United States since 193518 and has recently enjoyed a
resurgence of interest. The carbohydrate gram counting of today is reminiscent of the
early weighed diets but has been updated to use the large amount of self-management data
currently available. Carbohydrate choice counting is based on the portion of a 15-g
equivalent of carbohydrate on which the Exchange system is based (see below).
The Exchange system (Exchange Lists for Meal Planning),
with its periodic revisions, has been used for 50 years. In this system, foods are
categorized by lists that have similar macronutrient and energy values. Interestingly,
these lists are still generally the same as those used in the early weighed diets.
With the advent of the food label nutrition facts panel, other
counting methods of meal planning (fat gram, calorie) became easier to use.
While all current and past meal planning methods
have as their basis the chemical analysis of foods, recently there have been attempts to
differentiate carbohydrate foods based on postprandial glycemic effect (glycemic index or
GI).19 The GI for a given food is the response for that food compared with the
response for glucose, with glucose given a value of 100. Because the GI is a ratio rather
than a food or nutrient quantity and because glycemic response is a net result of a series
of processes (digestion and metabolism of food) involving numerous variables (e.g.,
individual metabolic variability, amount of resistant starch), meal planning by this
method appears to be slowly evolving.
What Will the New Millennium Bring?
Until the cure for diabetes is found or until the artificial pancreas, with its
internal and continual blood glucose sensor and insulin monitor, becomes a feasible
alternative, there will be a need for nutrition recommendations and meal planning methods
for people with diabetes and for people at risk for diabetes. But what track will this
take? Will we follow the narrow confines of previous cycles, or will the cycle be broken?
I firmly believe that in this new millennium we will break the cycle, and we will do it by
focusing on the process of medical nutrition therapy to help people meet their individual
goals, rather than on general, "one size fits all" recommendations. How
will this happen? Quality research! For example:
When associations take positions about clinical care
recommendations, they must be based as much as possible on strong scientific evidence with
accompanying expert consensus.20 In the past, diabetes nutrition
recommendations may have been based more on tradition or dogma rather than on scientific
evidence. (Remember that until just recently, "sugar" was "forbidden"
in diabetic meal planning.) In this new millennium, researchers will be developing
adequately powered and well-designed controlled clinical trials to answer nutrition
questions about understudied topics or controversial areas, such as protein or
available/unavailable carbohydrate and affect on glycemic response. Answering questions
with quality research will guide our nutrition recommendations.
In the new millennium, meal planning methods based on chemical
analyses will not be discarded but rather will be expanded and supplemented and will
become more and more flexible (witness the recent increased flexibility in timing and
amounts of carbohydrate by those using lispro or the insulin pump). To accomplish this,
though, requires both physicochemical and applied research. While controlled and
randomized applied and educational research studies are not easy to design and
conduct, they are necessary.
While we have always been cognizant of "individual"
diabetes treatment, this new millennium is bringing a "genetic revolution."21
In an editorial commentary in the Journal of the American Dietetic Association,
Monsen asks us to "Envision a day when each person receives a genetic blueprint of
their propensities for a particular disease. A nutrition professional will then take
into consideration a person's environmental determinants for a particular disease
and develop an individualized diet designed to prevent the diseasediabetes, for
example."22 Or, consider this: If a person already has diabetes, genes may
identify those at high or low risk for cardiovascular disease, and appropriate nutrition
recommendations can then be made.23 The challenge will be to design and conduct
quality research to see if this match of gene information and specific nutrition
recommendations makes a difference in outcome variables.
The First Cycle-Breaking Event Has Already Started!
The ADA is in the process of updating and revising the 1994 nutrition
recommendations.13 This process includes evaluating the scientific evidence
(quality published research studies) for a large number of interrelated nutrition topics,
scoring them based on type of scientific evidence provided, and coming to expert consensus
on recommendations that can be justified. The committee working on this project made a
preliminary report at the ADA's 60th Annual Meeting and Scientific Sessions in San
Antonio, Texas, in June. Stay tuned for updates!
1Marcus Aurelius Antoninus, 2nd century A.D. In Familiar
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Society, in Business, in Politics, and at Home. New York, Funk & Wagnalls, 1922.
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concepts in diabetic dietetics. Nutr Today 7(3):4-12, 1972.
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management of diabetes in adults. Proc Nutr Soc 38:365-71, 1979.
5Allen FM: The treatment of
diabetes. Boston Med Surg J 172:241-47, 1915.
6Joslin EP: The diabetic
diet. J Am Diet Assoc 3:89-92, 1927.
7Joslin EP, Root HF, White
P, Marble A: The Treatment of Diabetes Mellitus, 7th ed. Philadelphia, Lea &
Febiger, 1940, p. 212.
8Caso EK, Stare FJ:
Simplified method for calculating diabetic diets. J Am Med Assoc 133:169-71,
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14Todhunter EN: Food
composition tables in the USA. J Am Diet Assoc 37:209-14, 1960.
15U.S. Department of
Agriculture, Agricultural Research Service: USDA Nutrient Database for Standard Reference,
Release 13, 1999. Nutrient Data Laboratory Home Page,
16Wheeler ML: Using
nutrition software in diabetes management. In Intensive Management: Optimizing Therapy
and Outcomes for Type 1 and Type 2 Diabetes. Gillespie S, Ed. On the Cutting Edge (a
newsletter of the DCE practice group of The American Dietetic Association). 21(2):35-39,
17Pastors J, Holler H: Meal
Planning Approaches for Diabetes Management. Chicago, American Dietetic Association,
18Holler HJ, Pastors JG: Diabetes
Medical Nutrition Therapy. Chicago/Alexandria, Va. American Dietetic
Association/American Diabetes Association, 1997, p. 155-97.
19Brand-Miller J, Wolever
TMS, Colagiuri S, Foster-Powell K: The Glucose Revolution. New York, Marlowe
& Company, 1999.
20Field MJ, Lohr KN (Eds.): Clinical
Practice Guidelines: Directions for a New Program. Washington, DC, National Academy
21Patterson RE, Eaton DL,
Potter JD: The genetic revolution: change and challenge for the dietetics profession. J
Am Diet Assoc 99:1412-20, 1999.
22Monsen ER: Welcome to our
future. J Am Diet Assoc 100:11, 2000.
23Krauss RM: Genetic recipes
for heart-healthy diets. Am J Clin Nutr 71:668-69, 2000.
Madelyn L. Wheeler, MS, RD, FADA, CDE, is the Coordinator
of Research Dietetics for the Diabetes Research and Training Center at the Indiana
University School of Medicine in Indianapolis.
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