Diabetes Spectrum
Volume 13 Number 3, 2000, Page 116
Editorial

Cycles: Diabetes Nutrition Recommendations—Past, 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 treatment goals.

Caveats:

  • 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
Date Carbohydrate Protein Fat Calories Description
1152 B.C. High   Low Low Wheat grains, grapes, honey, berries3,4
150-200 A.D. High   Low Low Cereals, fruits, sweet wine3,4
1797-early 19th century Low High High  

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 suet only).

Dinner: fat and rancid old meat and game.

Supper: like breakfast4

1864 High   Low Low Diluted milk, occasionally boiled with white bread/barley4
End of 19th century 43% 18% 39% <800–1,000

Rice, oatmeal, potato, legume, or porridge diets (or "cures," as they were commonly called)4

1900-1920 Low   High Low (includes fasting) Allen's "starvation" diet5
1927 22% 16% 62% Normal Joslin's "weighed" diets6
1940 38% 17% 45% Normal 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
1950 43% 19% 37% Normal 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
1971 45% or more       American Diabetes Association10
1979 50-60% 12-20%

-the difference -<10% as saturated fat

  American Diabetes Association11
1986 55–60% 0.8g/kg total fat <30%   American Diabetes Association12
1994   10–20% <10% from saturated fat   American Diabetes Association13
21st century ? ? ?    

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:

  1. 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.

  2. 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.

  3. 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 disease—diabetes, 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!

References
1Marcus Aurelius Antoninus, 2nd century A.D. In Familiar Quotations: A Collection of Passages, Phrases, and Proverbs Traced to Their Sources in Ancient and Modern Literature. 9th ed. Bartlett J, ed. Boston, Little, Brown and Co., 1901. Available online at: http://www.bartleby.com/99/493.html

2Post E: Etiquette in Society, in Business, in Politics, and at Home. New York, Funk & Wagnalls, 1922.

3Wood FC, Bierman EL: New concepts in diabetic dietetics. Nutr Today 7(3):4-12, 1972.

4Leeds AR: The dietary 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, 1947.

9Caso EK: Calculation of diabetic diets. J Am Diet Assoc 26:575-83, 1950.

10American Diabetes Association: Principles of nutrition and dietary recommendations for patients with diabetes mellitus (Position Statement). Diabetes 20:633-34, 1971.

11American Diabetes Association: Principles of nutrition and dietary recommendations for individuals with diabetes mellitus (Position Statement). Diabetes 28:1027-30, 1979.

12American Diabetes Association: Nutritional recommendations and principles for individuals with diabetes mellitus (Position Statement). Diabetes Care 10:126-32, 1987.

13American Diabetes Association: Nutrition recommendations and principles for people with diabetes mellitus (Position Statement). Diabetes Care 23 (Suppl. 1):43-46, 2000.

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, http://www.nal.usda.gov/fnic/foodcomp

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, 2000.

17Pastors J, Holler H: Meal Planning Approaches for Diabetes Management. Chicago, American Dietetic Association, 1994.

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 Press, 1990.

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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