Recommendation for Diabetes Nutrition Care-A Literature Review
黃雅慧(Ya-Hui Huang)；藍玉芬(Yu-Fen Lan)；王香蘭(Hsiang-Lan Wang)
營養醫學治療 ； 實證醫學 ； 糖尿病 ； medical nutrition therapy ； evidence-based medicine ； diabetes
|Volume or Term/Year and Month of Publication||
11卷2期（2019 / 12 / 01）
1 - 13
糖尿病營養醫學治療為美國糖尿病協會以實證為基礎下進行的營養建議，從2002年迄今，每年更新證據來源並提出建議等級供醫病參據，內容包含適用族群、體重管理、飲食計畫、三大營養素、微量營養素、補充劑、鈉及非營養性甜味劑等議題。適用族群部分，東西方大型研究證實營養醫學治療（medical nutrition therapy, MNT）的介入在正常及肥胖體位葡萄糖耐受不良族群降低43～58%糖尿病發生率，而統合分析的文獻則顯示MNT介入可以降低15～46%孕期發展為妊娠糖尿病，降低第2型糖尿病族群0.95%糖化血色素。飲食計畫在血糖及體重控制的建議，目前飲食模式或營養素比例在研究間並無定論，過重及肥胖糖尿病族群以適度減重至少5%體重為彈性可行目標。糖尿病飲食建議以健康模式為出發點，並運用高營養密度食物種類；營養素方面，避免選擇會提高代謝風險的精緻糖與反式脂肪酸，全穀類、膳食纖維有助於體重及膽固醇管理，而富含單元及多元不飽和脂肪酸的地中海飲食相對改善空腹血糖、糖化血色素及降低心血管疾病風險。營養補充品部分，2012年魚油補充劑的文獻回顧顯示，血糖改善的成效尚無定論，而2018年2篇統合分析與文獻回顧探討其對血糖血脂代謝的影響結果並不一致，目前美國糖尿病協會對魚油的補充並未納入正面建議。其他微量營養素與補充劑包含抗氧化素、鉻、維生素D......等皆不建議在無缺乏風險下使用；至於糖尿病人低鈉飲食的介入在研究中平均降低6.90～7.11 mmHg的收縮壓及2.87～3.13 mmHg的舒張壓，但執行上須兼顧實務面均衡飲食及適口與可行性，目前鈉每日建議攝取量為2300 mg。最後，非營養性甜味劑的運用，現行實證提出可能減少水分攝取，因此強調足量天然原味的水分更趨重要。整體來說，糖尿病營養醫學治療應參照個人飲食的習慣、喜好及文化下進行，以健康飲食型態為方向來進行個別化及適切的建議。
Diabetes medical nutrition therapy (MNT) is an evidence-based nutrition recommendation from the American Diabetes Association (ADA). From 2002 to date, sources of evidence have been updated by ADA and recommended for doctor-patient reference data covering topics such as ethnicity, weight management, dietary planning, three macronutrients, micronutrients, supplements, sodium, and non-nutritive sweeteners. In the aspect of applicable ethnicity, large-scale studies in the East and the West have confirmed that the intervention of MNT has reduced the prevalence of diabetes among normal and obese impaired glucose tolerance groups by 43 ~ 58%. And the meta-analysis literature suggests that MNT intervention can reduce the risk of developing gestational diabetes mellitus during the pregnancy period by 15 ~ 46% and of glycated hemoglobin (A1C) by 0.95% in type 2 diabetes mellitus population. The dietary plans including macronutrients distribution of energy and dietary patterns for blood glucose and weight management is not conclusive at present. A 5% reduction in weight management provides a flexible target for overweight and diabesity-prone individuals. Nutrition recommendation for diabetes is mainly based on concept of implementing healthy diet and selecting foods with high nutrient densities. Foods high in refined sugar and trans-fatty acids, which would increase the metabolic risks, are recommended to avoid. Whole grain and dietary fiber which are beneficial for weight control and blood cholesterol management are encouraged. Mediterranean diet rich in mono and polyunsaturated fatty acids have been shown to improve fasting blood glucose, hemoglobin A1C and reduce the risks of cardiovascular diseases. Regarding nutritional supplements, studies published in 2012 have shown that fish oil supplements did not appear to improve glycemic control. Studies involving two meta-analysis during 2017 and 2018, have not shown consistent results on illustrating effects of fish oil supplementation on status of blood glucose and lipid control. Currently, the ADA also has not included positive recommendations for fish oil on metabolic control for diabetes patients. Other micronutrients and supplements, including antioxidants, chromium, vitamin D are not recommended to routinely supplement among diabetic individuals who are not deficient. As for effects of low-sodium diet intervention in diabetic patients, the average reduction of 6.90 ~ 7.11/2.87 ~ 3.13 mmHg in systolic/ diastolic pressure was observed. However, it is necessary to consider balance and palatability with the feasibility of the practical aspect of diets. Current recommendation for daily sodium allowance is 2300 mg. Finally, empirical studies have indicated that the use of non-nutritive sweeteners may result in the reduction of water intake. Therefore, consumption natural non-flavored water in sufficient quantities to be far more important is addressed. To conclude, MNT of diabetes should be carried out with considering individual dietary habits, preferences, and culture, appropriate nutrition recommendations should be provided on the basis of healthy eating patterns.