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FROM RESEARCH TO PRACTICE / PERSPECTIVES ON MEAL PLANNING
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DASH Eating Plan: An Eating Pattern
for Diabetes Management
Amy P. Campbell
■ IN BRIEF The DASH (Dietary Approaches to Stop Hypertension) eating
plan is an acceptable eating pattern for people who have diabetes. In addition
to promoting blood pressure control, this eating pattern has been shown to
improve insulin resistance, hyperlipidemia, and even overweight/obesity. This
Good Measures, LLC, Boston, MA balanced approach promotes consumption of a variety of foods (whole grains,
Corresponding author: Amy P. Campbell, fat-free or low-fat dairy products, fruits, vegetables, poultry, fish, and nuts) and
aepeterson@hotmail.com is appropriate for the entire family.
https://doi.org/10.2337/ds16-0084 he U.S. Department of Agri- Guidelines. Specifically, three food pat-
©2017 by the American Diabetes Association. culture (USDA) has described terns have been developed: the Healthy
Readers may use this article as long as the work Tseveral food patterns designed U.S.-Style Pattern, the Healthy
is properly cited, the use is educational and not
for profit, and the work is not altered. See http:// to help people follow the recom- Vegetarian Pattern, and the Healthy
creativecommons.org/licenses/by-nc-nd/3.0 Mediterranean-Style Pattern. The
for details. mendations set forth in its Dietary
76 SPECTRUM.DIABETESJOURNALS.ORG
campbell
American Diabetes Association, in its a diastolic blood pressure of 80–95 calorie needs. Based on the above
2013 position statement “Nutrition mmHg. Subjects in the study ini- recommendations, Table 1 provides
Therapy Recommendations for tially followed a control diet low in examples of daily and weekly serv-
the Management of Adults With fruits, vegetables, and dairy products, ings that meet DASH targets for a
Diabetes,” also promotes the use of a along with a fat intake of 37% of cal- 2,000-calorie eating plan (7,8).
variety of eating patterns to help with ories (representative of the typical In terms of macronutrient com-
the management of diabetes (1). American diet). After 3 weeks of this position, the nutrient goals of the
One of the eating patterns pro- run-in diet, subjects were random- DASH eating pattern are as follows:
moted in these recommendations ized to one of the following diets for Total fat: 27% of calories
is the DASH (Dietary Approaches 8 weeks: the control diet, a diet rich Saturated fat: 6% of calories
to Stop Hypertension) plan. This in fruits and vegetables, or a diet that Protein: 18% of calories
eating plan is one of several eating combined fruits, vegetables, and low- Carbohydrates: 55% of calories
patterns that is appropriate for dia- fat dairy foods. Body weight, physical Cholesterol: 150 mg
betes educators to recommend to activity, and sodium intake were held Sodium: 2,300 mg (A lower goal
their patients with diabetes. This constant during the trial. of 1,500 mg sodium was tested FROM RESEARCH T
dietary approach is a nutritious, bal- The combination diet reduced and found to be even better for Downloaded from http://diabetesjournals.org/spectrum/article-pdf/30/2/76/505261/76.pdf by guest on 02 January 2023
anced, and sustainable eating plan systolic blood pressure by 5.5 mmHg lowering blood pressure, partic-
that can improve a number of health and diastolic blood pressure by 3.0 ularly for middle-aged and older
parameters, including hypertension, mmHg, whereas the fruits and veg- individuals, African Americans,
insulin resistance, hyperlipidemia, etables diet reduced systolic blood and those who already had high
and overweight/obesity. People with pressure by 2.8 mmHg and dia- blood pressure [9].)
diabetes have a higher risk of develop- stolic blood pressure by 1.1 mmHg. Potassium: 4,700 mg
ing hypertension than people without Subgroup analyses showed that Calcium: 1,250 mg
diabetes; in addition, the percentage African Americans and individuals Magnesium: 500 mg O PRA
of adults with diabetes ≥18 years of with hypertension showed the great- Fiber: 30 g
age who have hypertension was 57.1% est reductions in blood pressure (3).
in 2009 compared to 46.2% in 1995 DASH Diet: What Is It? The DASH eating pattern is CTICE
(2). Clearly, efforts to help prevent closely aligned with the USDA’s
and manage hypertension must be The NHLBI, part of the National dietary recommendations, as outlined
increased, especially in the diabetes Institutes of Health (NIH), promotes in the 2015–2020 Dietary Guidelines
population. the DASH diet, or eating pattern, as a for Americans. As described in chapter
The appeal of the DASH eating means of preventing and controlling 1 of the USDA guidelines, the “Key
pattern for patients is that it is also blood pressure without the use of Recommendations” for healthy eat-
practical; it does not require spe- medication. The DASH eating pat- ing patterns are as follows:
cial foods or supplements, and it is tern is also promoted as a healthful Consume a healthy eating pattern
an approach that is appropriate for option for the general population that accounts for all foods and
patients’ entire family to follow. This (4–6). beverages within an appropriate
article introduces diabetes educators The DASH eating pattern pro- calorie level.
to the DASH eating pattern in more motes blood pressure reduction by A healthy eating pattern includes:
detail, providing the evidence behind encouraging the consumption of ❍ A variety of vegetables from
the plan and suggesting practical tips foods that are low in saturated fat, all of the subgroups—dark
for introducing the DASH eating total fat, cholesterol, and sodium and green, red and orange, legumes
plan to patients. high in potassium, calcium, magne- (beans and peas), starchy, and
sium, fiber, and protein. In terms of other
Overview of the DASH Trial actual food choices, the DASH eating ❍ Fruits, especially whole fruits
The DASH eating plan was developed pattern encourages whole grains, fat- ❍ Grains, at least half of which
as an approach to help lower blood free or low-fat dairy products, fruits, are whole grains
pressure without the use of medica- vegetables, poultry, fish, and nuts. ❍ Fat-free or low-fat dairy,
tion. A multicenter trial, funded by Foods that are limited include fatty including milk, yogurt, cheese,
the National Heart, Lung, and Blood meats, full-fat dairy products, tropi- and/or fortified soy beverages
Institute (NHLBI) and published in cal oils (e.g., coconut, palm, and palm ❍ A variety of protein foods,
1997, was conducted to study the kernel oils), and sweets and sugar- including seafood, lean meats
effects of dietary patterns on blood sweetened beverages. and poultry, eggs, legumes
pressure in 459 adults with a systolic The number of servings of foods (beans and peas), nuts, seeds,
blood pressure of <160 mmHg and is based on a person’s estimated and soy products
VOLUME 30, NUMBER 2, SPRING 2017 77
FROM RESEARCH TO PRACTICE / PERSPECTIVES ON MEAL PLANNING
TABLE 1. Examples of Daily and Weekly Servings That Meet ❍ Oils
DASH Targets for a 2,000-Calorie Eating Plan (7,8) A healthy eating pattern limits:
Food Group Daily Servings Serving Sizes ❍ Saturated fats and trans fats,
(except as noted) added sugars, and sodium
Grains and grain 7–8 1 slice bread Key Recommendations that are
products 1 cup ready-to-eat quantitative are provided for several
cereal* components of the diet that should be
1/2 cup cooked rice, limited. These components are of par-
pasta, or cereal ticular public health concern in the
Lean meats, poultry, ≤2 3 oz cooked lean meat, United States, and the specified limits
and fish skinless poultry, or fish can help individuals achieve healthy
Vegetables 4–5 1 cup raw leafy eating patterns within calorie limits:
vegetable Consume <10% of calories per
1/2 cup cooked day from added sugars
vegetable Consume <10% of calories per Downloaded from http://diabetesjournals.org/spectrum/article-pdf/30/2/76/505261/76.pdf by guest on 02 January 2023
6 oz vegetable juice day from saturated fats
Consume <2,300 mg per day of
Fruit 4–5 1 medium piece of fruit sodium
1/4 cup dried fruit If alcohol is consumed, it should
1/2 cup fresh, frozen, be consumed in moderation—≤1
or canned fruit drink per day for women and ≤2
6 oz fruit juice drinks per day for men—and only
Low-fat or fat-free dairy 2–3 8 oz milk by adults of legal drinking age
foods 1 cup yogurt Both the USDA dietary guide-
1 1/2 oz cheese lines and the DASH eating pattern
Nuts, seeds, and dry 4–5 per week 1/3 cup or 1 1/2 oz nuts strongly encourage the intake of
beans 1 Tbsp. or 1/2 oz seeds vegetables, fruits, whole grains, and
lower-fat dairy products, while limit-
1/2 cup cooked dry ing the intake of sugars, saturated fat,
beans and sodium (5).
Fats and oils† 2–3 1 tsp. soft margarine DASH–Sodium Trial
1 tsp. low-fat Interestingly, although the DASH
mayonnaise diet was not low in sodium (provid-
2 Tbsp. light salad ing 2,400 mg of sodium per day),
dressing blood pressure was still reduced. To
1 tsp. vegetable oil understand the effect of sodium re-
Sweets ≤5 per week 1 Tbsp. sugar striction, the DASH–Sodium trial
1 Tbsp. jelly or jam was conducted. This trial included
1/2 oz jelly beans 412 subjects who were randomized
8 oz lemonade to a control diet or the DASH diet
Sodium†† <2,300 mg Total from prepared/ for 90 days. Within each group, sub-
packaged foods and jects were then assigned to three diets:
added during cooking a high-sodium diet (3.5 g/day), a
or at the table moderate-sodium diet (2.3 g/day), or
*Serving sizes vary between 1/2 and 1 1/4 cups. Check product nutrition a low-sodium diet (1.2 g/day), each
labels. for 30 days. For those on the DASH
†Fat content changes serving counts for fats and oils (e.g., 1 Tbsp. regular diet, the greater the reduction in so-
salad dressing is 1 serving, whereas 1 Tbsp. low-fat salad dressing is 1/2 dium, the greater was the reduction
serving, and 1 Tbsp. fat-free salad dressing is 0 servings). in blood pressure, although there was
††Limiting sodium to 1,500 mg daily lowers blood pressure even further than no significant difference on diastol-
2,300 mg sodium daily (8). ic blood pressure between the high-
and moderate-sodium intake levels.
Furthermore, lowering sodium intake
78 SPECTRUM.DIABETESJOURNALS.ORG
campbell
to 1.2 g/day would be challenging, Is the DASH eating pattern ben- DASH Eating Pattern in
given the amount of sodium used by eficial for people who have diabetes? Gestational Diabetes
the food industry in food processing As previously mentioned, the DASH A healthy eating plan is a key factor in
(4,10). eating pattern can provide upwards the management of gestational diabe-
OmniHeart Study of 55% of calories from carbohydrate, tes mellitus (GDM); specifically, the
The OmniHeart (Optimal Macro- which may be too high a carbohy- goal is to prevent or reduce adverse
nutrient Intake Trial for Heart drate intake for some people with maternal and newborn outcomes
Health) study compared three heart- type 2 diabetes. Furthermore, there without instigating any short-term
healthy diets that were known to low- is little research demonstrating the harmful effects. Various dietary ap-
er blood pressure and improve blood glycemic benefits of the DASH eating proaches have been studied, includ-
lipids. These three diets were based plan for people who have diabetes. ing a low–glycemic index (GI) diet, a
on the DASH diet but differed in the Yet, in one study of 31 subjects with low-carbohydrate diet, and a calorie-
amount of carbohydrate, protein, and type 2 diabetes (14), the DASH eat- restricted diet. In a systematic review
ing plan did improve blood lipids and and meta-analysis of randomized
unsaturated fat, while being equiva- blood pressure while also decreasing clinical trials of dietary interventions FROM RESEARCH T
lent in calories. The higher protein A1C (by 1.7 percentage points) and in GDM, Viana et al. (19) conclud- Downloaded from http://diabetesjournals.org/spectrum/article-pdf/30/2/76/505261/76.pdf by guest on 02 January 2023
(25 vs. 15% of calories) and higher fasting blood glucose levels (by 29%). ed that, although the low-GI eating
unsaturated fat (10 vs. 8% of calo- Of note, De Paula et al. (15) found plan was associated with less frequent
ries) diets showed the most benefit on that fruits and vegetables were the insulin use and lower birth weight
blood pressure and blood lipids and two food groups of the DASH eating than the other diets, the DASH diet
reduced the estimated 10-year risk of plan that helped to lower blood pres- also holds promise for patients with
heart disease compared to the higher- sure in a group of 225 subjects with GDM. In a small trial (20), women
carbohydrate diet. Of note, the high- type 2 diabetes. with GDM followed the DASH diet
er-protein diet emphasized plant However, the benefits of the for 4 weeks. The DASH diet during O PRA
sources of protein, which have been DASH eating plan may be applicable pregnancy lowered insulin use, re-
associated with reduced blood pres- to people who have type 2 diabetes in duced cesarean rates, and lowered
sure (11). Although the OmniHeart other ways. For example, the diets of birth weights. Although the DASH CTICE
study was not specifically geared to- women in the Nurses’ Health Study approach looks promising for the
ward diabetes or glycemic manage- and the Nurses’ Health Study II, and management of GDM, further re-
ment, the fact that heart disease is the of men in the Health Professionals search is warranted, as, in this study,
leading cause of death among people Follow-Up Study were measured the diet was not followed throughout
with diabetes makes its results appli- every 4 years. Adherence scores the pregnancies and deliveries.
cable to this population. were computed for the Alternate DASH Eating Pattern for
DASH Eating Pattern for Mediterranean Diet, the Alternate Diabetes Prevention
Diabetes Health Eating Index–2010, and The DASH eating plan or DASH-like
The DASH eating pattern has prov- the DASH diet. Improvement in eating plans have also led to improve-
en to be beneficial for those who are all three of these scores was associ- ments in insulin sensitivity, further
aiming to control or prevent hyper- ated with less weight gain, especially demonstrating that this type of eating
tension. Nearly two out of three indi- in younger women or overweight plan may be helpful for individuals
viduals with diabetes have hyperten- individuals (16). Weight control is with prediabetes or who are at risk
sion (12), so it is reasonable to expect linked with improved glycemic con- for type 2 diabetes (21,22). A meta-
that the DASH eating plan would be trol in people with type 2 diabetes analysis (23) of prospective cohort
of benefit for people who have both (17). Interestingly, the DASH diet
is ranked by U.S. News & World studies looked at the differences
hypertension and diabetes. In a study Report as being “#1 in best diets over- among various diets’ effects in pre-
by Paula et al. (13), 40 patients with all” for helping to manage not only venting type 2 diabetes. The au-
type 2 diabetes and uncontrolled blood pressure but also weight (18). thors concluded that several diets,
blood pressure were randomized to Although the DASH eating pattern is including the DASH diet and the
either the DASH diet and increased not specifically aimed at weight loss, Mediterranean diet, were associated
physical activity or a control diet and its emphasis on fruits and vegetables, with a 20% decrease in the risk of fu-
instructions to maintain their usual lower-fat dairy foods, and reduced ture type 2 diabetes.
level of physical activity. Reductions consumption of red meat and sweets The ADA’s nutrition recommen-
in blood pressure were greater in the can be beneficial for patients who are dations for adults with diabetes state
intervention group compared to the aiming to lose weight or maintain that “there is no ‘ideal’ conclusive
control group. their weight at a healthy level. eating pattern that is expected to
VOLUME 30, NUMBER 2, SPRING 2017 79
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