3.5.0.0 Car­bo­hy­drates

Stud­ies ex­am­in­ing the ideal amount of car­bo­hy­drate in­take for peo­ple with di­a­betes are in­con­clu­sive, al­though mon­i­tor­ing car­bo­hy­drate in­take and con­sid­ering the blood glu­cose re­sponse to di­etary car­bo­hy­drate are key for im­prov­ing post­pran­di­al glu­cose con­trol (82,83). The lit­er­a­ture con­cern­ing glycemic index and glycemic load in in­di­vid­u­als with di­a­betes is com­plex, often yield­ing mixed re­sults, though in some stud­ies low­er­ing the glycemic load of con­sumed car­bo­hy­drates has demon­strat­ed A1C re­duc­tions of 0.2% to 0.5% (84,85). Stud­ies longer than 12 weeks re­port no significant influence of glycemic index or glycemic load in­de­pen­dent of weight loss on A1C; how­ev­er, mixed re­sults have been re­port­ed for fast­ing glu­cose lev­els and en­doge­nous in­sulin lev­els.

For peo­ple with type 2 di­a­betes or predi­a­betes, low-‍car­bo­hy­drate eat­ing plans show po­ten­tial to im­prove glycemia and lipid out­comes for up to 1 year (62–64,86–89). Part of the chal­lenge in in­ter­pret­ing low-‍car­bo­hy­drate re­search has been due to the wide range of def­i­ni­tions for a low-‍car­bo­hy­drate eat­ing plan (85,86). As re­search stud­ies on low-‍car­bo­hy­drate eat­ing plans gen­er­ally in­di­cate chal­lenges with long-‍term sus­tainabil­i­ty, it is im­por­tant to reas­sess and in­di­vid­u­alize meal plan guid­ance reg­u­lar­ly for those in­ter­est­ed in this ap­proach. Providers should main­tain con­sis­tent med­i­cal over­sight and rec­og­nize that cer­tain groups are not ap­pro­pri­ate for low-‍car­bo­hy­drate eat­ing plans, in­clud­ing women who are preg­nant or lac­tat­ing, chil­dren, and peo­ple who have renal dis­ease or dis­or­dered eat­ing be­hav­ior, and these plans should be used with cau­tion for those tak­ing SGLT2 in­hibitors due to po­ten­tial risk of ke­toaci­do­sis (65,66). There is inad­e­quate re­search about di­etary pat­terns for type 1 di­a­betes to sup­port one eat­ing plan over an­oth­er at this time.

Most in­di­vid­u­als with di­a­betes re­port a mod­er­ate in­take of car­bo­hy­drate (44–46% of total calo­ries) (51). Ef­forts to mod­i­fy ha­bit­u­al eat­ing pat­terns are often un­suc­cess­ful in the long term; peo­ple gen­er­ally go back to their usual macronu­tri­ent dis­tri­bu­tion (51). Thus, the rec­om­mend­ed ap­proach is to in­di­vid­u­alize meal plans to meet caloric goals with a macronu­tri­ent dis­tri­bu­tion that is more con­sis­tent with the in­di­vid­u­al’s usual in­take to in­crease the like­li­hood for long-‍term main­te­nance.

As for all in­di­vid­u­als in de­vel­oped coun­tries, both chil­dren and adults with di­a­betes are en­cour­aged to min­i­mize in­take of refined car­bo­hy­drates and added sug­ars and in­stead focus on car­bo­hy­drates from veg­etables, legumes, fruits, dairy (milk and yo­gurt), and whole grains. The con­sump­tion of sugar-‍sweet­ened bev­er­ages (in­clud­ing fruit juices) and pro­cessed “low-‍fat” or “non­fat” food prod­ucts with high amounts of refined grains and added sug­ars is strong­ly dis­cour­aged (90-92). In­di­vid­u­als with type 1 or type 2 di­a­betes tak­ing in­sulin at meal­time should be of­fered in­ten­sive and on­go­ing ed­u­ca­tion on the need to cou­ple in­sulin ad­min­is­tra­tion with car­bo­hy­drate in­take. For peo­ple whose meal sched­ule or car­bo­hy­drate con­sump­tion is vari­able, reg­u­lar coun­sel­ing to help them un­der­stand the com­plex re­la­tion­ship be­tween car­bo­hy­drate in­take and in­sulin needs is im­por­tant. In ad­di­tion, ed­u­ca­tion on using the in­sulin-to-car­bo­hy­drate ra­tios for meal plan­ning can as­sist them with ef­fectively mod­i­fying in­sulin dos­ing from meal to meal and im­prov­ing glycemic con­trol (51,82,93–96). In­di­vid­u­als who con­sume meals con­tain­ing more pro­tein and fat than usual may also need to make meal­time in­sulin dose ad­just­ments to com­pen­sate for de­layed post­pran­di­al glycemic ex­cur­sions (97-99). 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 (35).