New EASD dietary guidelines for diabetes management and prevention

The guidelines encourage increased intake of plant-based and minimally-processed foods, and the restriction of free sugars, sodium, and saturated fats

New dietary recommendations for diabetes management have been published by the Diabetes and Nutrition Study Group (DNSG) of the European Association for the Study of Diabetes (EASD).

They are designed for health professionals, including those with and without dietetic training, who treat and advise people with diabetes, and replace the previous recommendations from 2004. The new dietary recommendations reflect the current evidence-base and will continue to be updated.

In putting together the new guidelines, the DNSG commissioned new systematic reviews and meta-analyses on key topics and drew on the broader evidence available. They have strengthened and expanded on the previous recommendations to include advice relating to dietary patterns, environmental sustainability, food processing, patient support, and remission of type 2 diabetes. They used the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach to determine the certainty of evidence for each recommendation based on findings from the commissioned and identified systematic reviews. 

Their findings indicate that a range of foods and dietary patterns are suitable for diabetes management, with key recommendations for people with diabetes being largely similar to those for the general population.

Key messages are to consume plenty of minimally-processed plant foods such as wholegrains, vegetables, whole fruit, legumes, nuts, seeds and non-hydrogenated non-tropical vegetable oils, while minimising the consumption of red and processed meats, sodium, sugar-sweetened beverages, and refined grains.

Very low carbohydrate ketogenic diets are not recommended because they have been associated with hypoglycaemia, ketoacidosis, vitamin and mineral deficiencies, and greater mortality.

The DNSG believe that, if adhered to, the new dietary guidelines will improve patient outcomes. The key recommendations are as follows:

Food-based approaches in diabetes management

Recommendations

Although enjoying a variety of nutritious foods is encouraged, there are key foods to base meals and snacks around:

• Minimally-processed wholegrains and wholegrain foods are recommended to improve blood glucose control, cardiovascular risk factors and body weight. Moderate
• Whole vegetables and fruit are recommended to improve blood glucose control and other cardiometabolic risk factors. Moderate
• Legumes are recommended to improve blood glucose control and other cardiometabolic risk factors. Low
• Nuts and seeds are recommended to improve blood glucose control and other cardiometabolic risk factors without increasing risk of obesity. Moderate

Energy-balance and weight management in diabetes management

Recommendations

• People with diabetes who are overweight or obese should be supported with evidence-based treatments to achieve and maintain weight-loss. High
• A variety of weight-loss diet types and macro-nutrient compositions, supported by trained health professionals, can be used for weight-loss induction and maintenance, provided that they meet other dietary recommendations. High
• Nutritionally complete low-energy formula products can be used, either temporarily for weight-loss induction as ‘total diet replacement’ (replacing all meals), or by replacing one-to-two meals/day. Replacing one meal/day or three-to-six meals/week can also be used for longer-term weight-loss maintenance. Moderate
• Neither extreme high-carbohydrate, nor very-low carbohydrate ketogenic diets are recommended for weight-loss. High
• Remission of type 2 diabetes (HbA1c <48mmol/mol [<6.5 per cent] without glucose-lowering medication) in people who are overweight or obese can be achieved through sustained weight loss. High
• A low-energy total diet replacement programme (eg, 3,500kJ/day [840kcal/day] for 12-to-20 weeks), provided by trained health professionals, with carefully adjusted glucose-lowering and anti- hypertensive medications, is recommended to provide sufficient weight-loss (10-to-15 per cent body weight or greater) to induce remission of type 2 diabetes. Following weight-loss, long-term low-intensity support for weight-loss maintenance is recommended. High

Carbohydrate intakes in diabetes management

Recommendations

• A wide range of carbohydrate intakes are acceptable, provided recommendations relating to dietary fibre, sugars, saturated fats, and protein intakes are met. Moderate
• Very low carbohydrate intakes, such as with ketogenic diets, are not recommended. Moderate
• Foods naturally high in dietary fibre should be encouraged. High
• Dietary fibre intake should be at least 35g per day
• (4g per 100kJ). Moderate
• Minimally-processed wholegrains, vegetables, legumes, seeds, nuts, and whole fruits should be recommended as sources of dietary fibre. Moderate
• Fibre-enriched foods and fibre supplements should be considered when sufficient intakes cannot be obtained from diet alone. Moderate
• Diets with a low glycaemic index or low glycaemic load can be recommended, provided their composition is consistent with overall diet recommendations for dietary fibre, sugars, saturated fats, and protein. Moderate
• Intakes of free or added sugars should be below 10 per cent of total energy intake. Moderate
• Non-nutritive sweeteners can be used to replace sugars in foods and beverages. Moderate
• Carbohydrate counting may be a useful approach to determine mealtime insulin dose. Moderate

In putting together the new guidelines, the DNSG commissioned new systematic reviews and meta-analyses on key topics, and drew on the broader evidence available

Dietary fat intake in diabetes management

Recommendations

• Dietary fats should mainly come from plant-based foods high in both mono and polyunsaturated fats such as nuts, seeds, and non-hydrogenated non-tropical vegetable oils. Low
• Saturated and trans-fat intakes should comprise <10 per cent and <1 per cent of total energy, respectively. Low
• When reducing saturated fats, replacement should be mainly with plant-based polyunsaturated fats containing both n-6 and n-3 fatty acids, and monounsaturated fats, as found in nuts, seeds, and non-hydrogenated non-tropical vegetable oils. Low

Protein intakes in diabetes management

Recommendations

• For weight-stable, normal weight people with diabetes a protein intake of 10-to-20 per cent total energy is recommended for people under the age of 65 years with an estimated glomerular filtration rate (eGFR) >60ml/min per 1.73m². Higher intakes (15-to-20 per cent total energy) are recommended for those aged 65 years or older. Low
• For people with type 2 diabetes who are overweight or obese with an eGFR >60ml/min per 1.73m² a protein intake of 23-to-32 per cent may be recommended in the short-term (up to 12 months) in the context of a weight-loss diet. Low
• For people with moderate diabetic nephropathy (stage 3a:eGFR <60 but >45ml/min per 1.73m²) a protein intake of 10-to-15 per cent is recommended. Low

Traditional dietary patterns and therapeutic diets in diabetes management

Recommendations

• A variety of dietary patterns emphasising the consumption of whole grains, whole vegetables and fruit, legumes, nuts, seeds, and hydrogenated non-tropical vegetable oils, while minimising the consumption of meat (especially red and processed meat), sugar-sweetened beverages, sweets, and refined grains are recommended. These patterns include:
• Mediterranean dietary pattern to improve glycaemia and other cardiometabolic risk factors (moderate) and reduce risk of cardiovascular disease (CVD) and all-cause mortality (low-to-moderate).
• Nordic dietary pattern to improve BMI (high) and other cardiometabolic risk factors (low-to-moderate) and reduce the risk of CVD (low-to-moderate).
• Vegetarian dietary pattern to improve glycaemia and other cardiometabolic risk factors (moderate).

Prevention of type 2 diabetes

Recommendations

• People who are overweight or obese are at increased risk of type 2 diabetes and should aim for at least 5 per cent weight-loss by adopting an intensive lifestyle intervention involving an energy-restricted diet and increased physical activity. High
• Energy intake and physical activity appropriate to individual requirements are recommended to ensure long-term maintenance of a healthy body weight. High
• Achieving a combination of low-risk lifestyle behaviours such as following a healthy dietary pattern (eg, Mediterranean, Nordic, vegetarian), undertaking regular physical activity, avoiding being overweight or obese, and not smoking, are recommended. Moderate

Reference
Diabetes and Nutrition Study Group (DNSG) of the European Association for the Study of Diabetes (EASD). Evidence-based European recommendations for the dietary management of diabetes. Diabetologia. 2023 Jun;66(6):965-985