The DDG practice recommendations are updated regularly during the second half of
the calendar year. Please ensure that you read and cite the respective current
version.
Updates To Content And Different Recommendations Compared To The Previous
Year’s Version
Recommendation 1: Statement on the Use of Automatic Insulin Dosing (AID)
Systems
Reason: How to proceed in case of system failure
Recommendation 2: Notice on dose adjustment for evening protein-rich
food
Reason: Risk of hypoglycemia
ADI Acceptable Daily Intake
CGM Continuous glucose monitoring
EFSA European Food Safety Authority
EN% Energy percent
GI Glycemic index
MNA Mini Nutritional Assessment
n-9RCFA Red cell phospholipid fatty acids
rtCGM Real-time CGM
iscCGM Intermittent-scanning CGM
T1Dm Type 1 diabetes mellitus
Preamble
This practice recommendation is aimed at all people with type 1 diabetes and all
professional groups that care for people with type 1 diabetes.
The most recent “Evidence-based dietary recommendations for the treatment
(and prevention) of diabetes mellitus” are from the year 2005 [1].
In accordance with the demand for individualization of therapy, counseling,
empowerment and diabetes self-management [2]
[3] and in view of the consensus report
“Nutrition Therapy for Adults with Diabetes or Prediabetes” [4]
[5], the
Nutrition Committee of the DDG has set itself the goal of presenting evidence-based
practice recommendations on nutrition for the various (sub)types of diabetes
mellitus in a summarizing body of work. A separate presentation according to
diabetes types and forms of treatment is considered necessary, as the therapeutic
significance of nutrition differs significantly in each case and must be considered
against the background of different drug therapy components. This results in the
division of dietary recommendations into two sections: for people with type 1
diabetes and for people with type 2 diabetes.
Nutritional recommendations should consider the individual life and nutritional
habits of each person with diabetes mellitus with the goal of maintaining the
nutritional regime for as long as possible.
Many variables, such as exercise, stress, meal composition, medication, etc., have an
impact on blood glucose values with a high individual variability.
Recommendations to modify the regular diet – and thus limit it from the
patient’s perspective – are justified if this lifestyle change can
be used to achieve a clinically-relevant health benefit or to prevent a health
threat based on evidence.
It has been observed that authors of observational and experimental studies with a
small number of test persons repeatedly derive general recommendations from their
study results, although this is not justified, especially when it comes to
recommendations for the preference of singular foods (groups).
In the practice recommendations on diet in type 1 diabetes presented here, it is
clear that the evidence for general recommendations is limited. Individual testing
(CGM) of the glycemic effects of food intake is important in many aspects of
nutrition. The empirical values thus determined – in addition to the
patient’s own food preferences – provide a suitable basis for
individual food selection and the appropriate strategy for insulin application.
Nutritional aspects in relation to glycemia and glycemic target
parameters
Nutritional aspects in relation to glycemia and glycemic target
parameters
Estimation of carbohydrate quantities
Recommendation
Patients should
-
Correctly estimate the amount of CHO ingested per meal to an accuracy
of 1 carbohydrate unit (CU), equivalent to 10 g of CHO (as a
basis for algorithm-guided dosing of prandial insulin)
-
Know their individual postprandial glucose trends.
-
Perform repeated testing of a standardized meal ideally via a rtCGM
or iscCGM
Comment
There are few evidence-based studies available but practical experience shows
the following results. It is of crucial importance for the treatment of type
1 diabetes that patients are enabled to assess the glucose efficacy of their
diet in order to adjust insulin dosage accordingly [6]
[7]
[8]. Structured training
should provide the basis for this. The training should be repeatedly [6]
[8].
There is no recommendation on the amount of carbohydrates [7]
[8].
How much of each macronutrient should be eaten has to be considered on an
individual basis. The evaluation of postprandial glucose trends via rtCGM
and iscCGM can help to choose the right bolus variant or the correct
injection-to-meal interval [9]. Especially
in cases of gastroparesis, the control of different bolus variants can
ensure an individually-adapted trend.
Patients with a fixed dose must estimate the correct amount of carbohydrate
in their meals [7]. It is also important
to estimate carbohydrate quantities correctly during pregnancy for moderate
postprandial glucose trends.
Individualized nutrition and the corresponding adaptation of insulin dose
algorithms can lead to a better acceptance of the disease. This is
particularly important for children and adolescents. Currently, estimating
the consumed carbohydrate (CHO) amounts is also recommended when using AID
(Automatic Insulin Dosing) systems – with preprandial input of the
CHO amount into the system. Metabolizing the carbohydrate uptake solely via
the AID autocorrection cannot be recommended at present despite extensive
experience. The currently-available systems are also not approved for this.
In the event of an AID system failure, the correct estimation of KH
quantities must be taught and mastered.
There is no hard evidence for assessing carbohydrate units. In a pilot
study, 256 people with T1Dm were divided into two groups: trained and
untrained in nutrition. When comparing the two groups, patients with
training had significantly lower HbA1c
(7.8±1.3–7.4±0.9% vs.
7.5±0.8–7.5±1.1%) and less hypoglycemia
[10].
In a study of 43 children aged 8.5–17.7 years with ICT, postprandial glucose
trends were examined as a function of carbohydrate levels. It was shown that it is
necessary to accurately estimate to within 10 g of carbohydrates to remain in
the postprandial target [11]. Another study with type
1 patients exhibited similar results and the importance of good training for
carbohydrate calculation [12]. The importance of this
was also demonstrated in a study of 102 children and adolescents aged 8.3–18.1
years. Here the mean gram error was significantly correlated negatively with the
HbA1c (r=-0.7). It was also shown that the longer the children
calculated carbohydrates, the greater the mean percentage error (r=0.173). The
authors therefore concluded that children and their caregivers can estimate well, but
that a gram calculation is not better than a portion calculation. Repeated age-related
training is necessary to reduce the error rate [13].
It has also been shown that for a good postprandial setting, accurate carbohydrate
calculation within 10 g is important. In this study of 30 children (8–18
years) with CSII therapy, it was also shown that accuracy is not related to
quantity.
Glycemic index
Recommendation
-
The individual testing of the glycemic response (by glucose
self-monitoring) to the preferred foods and meals is of great
importance in order to develop and implement an adequate individual
prandial insulin application strategy (including injection timing
and application mode for CSII).
-
There is no evidence that generally giving preference to low GI
carbohydrate carriers helps people with T1Dm achieve their
therapeutic goals.
-
For individual meals, it is recommended to cover carbohydrate-rich
foods with a low GI (below approx. 30) with significantly less
prandial insulin in order to prevent hypoglycemia, especially in the
case of an almost normoglycemic metabolic control.
Comment
There are many GI tables in circulation, but only a few published in
scientific papers [14]
[15]
[16]
are suitable to be used to define the GI of carbohydrate-containing foods.
In order to assess the GI, it should be taken into account that the GI
values are basically average values from several studies. Variety, degree of
ripeness, place of cultivation/production and, if applicable, recipe
of a foodstuff all have a decisive influence on the GI. For bananas, for
example, an average GI of 48 (ref. glucose=100%; volunteers:
type 2 diabetes) is reported – with a range of GI 30 to GI 58 for
the 9 studies considered [14]. For cooked
white rice (mean GI: 59), the range even goes from GI 43 to GI 112 [14].
Studies of adults with type 1 diabetes under experimental conditions that
compared the blood glucose response to (single) whole meals with low vs.
high GI [17]
[18]
[19] have found
significantly lower blood glucose responses after low GI meals and observed
hypoglycemia when low GI carbohydrate carriers (lentils) are covered with
the usual dose of mealtime insulin [17].
A study of blood glucose responses over a full day (4 meals per day) with
insulin pump therapy [20] has shown that
near-normoglycemic metabolic control is achieved regardless of GI when
patients adequately adjust their insulin administration.
Medium- and long-term studies on the effects of an average low-GI diet vs. an
average high-GI diet in adults with type 1 diabetes under everyday
conditions are scarce; they date back mainly to the 1990s and had few
participants [18]
[21].
In a meta-analysis from 2010 [22], 2
studies in adults with type 1 diabetes were included; however, they exhibit
methodological deficiencies and are not relevant for statements on GI [23]
[24].
A recent review of the relevance of the 2018 GI in adults did not include
people with type 1 diabetes [25].
Studies in children and adolescents with type 1 diabetes were mainly
conducted on small numbers of subjects and under experimental conditions
[26]
[27]
[28], so that no fundamental
benefits and no favorable recommendations can be derived from them. A study
from the year 2001 [29] examined 2
different dietary recommendations for 52 weeks in children with type 1
diabetes. The results of this study are often used as an argument for the
benefit of a low GI diet. However, this is not justified, since the study
did not intend to compare a low-GI diet with a high-GI diet, but primarily
compared a diet with a fixed carbohydrate distribution
(“carbohydrate framework”) vs. a diet with flexible
carbohydrate intake. The evaluation of the subjects’ dietary
protocols showed identical values for the mean GI of the consumed
carbohydrate carriers for both groups.
Overall, there is no evidence from the available multi-week dietary studies
that people with type 1 diabetes should give preference to low GI
carbohydrate carriers in their diet.
With regard to the consumption of individual foods/meals (according
to the “acute food/meal studies” and clinical
experience), special consideration of foods containing carbohydrate with a
very low GI (below approx. 30) or a very high GI (above approx. 90) seems
advisable.
Foods with a very low GI (below approx. 30: e. g. pulses, nuts)
should be covered with less prandial insulin to avoid hypoglycemia in the
case of almost normoglycemic preprandial blood glucose values, while those
with a very high GI (especially sugar-sweetened drinks) are more likely to
be reserved for self-treatment of hypoglycemia.
Individual testing of the glycemic response (through glucose self-monitoring)
to the preferred foods and meals is of great importance, similar to finding
an optimal personal strategy for physical activity in diabetes.
In this way it is possible to determine the factors, in addition to the
amount of carbohydrates ingested, which affect the postprandial blood
glucose response, and these include, in addition to the GI, e. g.
fluid intake, fat, protein, alcohol content of accompanying foods,
preprandial glycemia, general glycemic control, body weight, physical
activity, absorption of insulin from the application site.
The evaluation of postprandial glucose trends via rtCGM and iscCGM can help
to select the appropriate insulin dose and bolus variant or
injection-to-meal interval. People with ICT therapy can act with the options
of injection-to-meal intervals or split boluses. People with CSII therapy
can act via dual boluses/multiwave boluses or delayed boluses and
injection-to-meal intervals. Basic criteria for the decision are initial
glucose levels, carbohydrate amounts (CHO) and the GI of the diet.
(Nocturnal) hypoglycemic events must be prevented especially resulting from
evening meals with a very low GI.
The blood glucose response is always seen in combination with the insulin
strategy. In practice, it has proven to be useful to vary the time of
injection or, in the case of CSII, the insulin application mode for certain
foods and starting situations according to personal experience.
Insulin requirements for protein and fat-rich meals
Recommendation
-
There is no evidence that people with type 1 diabetes generally
estimate their meals quantitatively for energy, fat and protein
content in order to derive an additional insulin bolus.
-
The blood glucose response to very high-fat or high-protein meals
varies from person to person and should be determined and documented
by self-monitoring. On this basis, an additional insulin requirement
may be developed individually.
-
Increasing the prandial insulin dose for high-protein evening meals
increases the risk of night-time hypoglycemia.
-
People with type 1 diabetes should be able to assess the effect of
fats and proteins on glucose levels.
Comment
Protein-rich meals also result in a certain insulin requirement and can lead
to postprandial delayed and sustained hyperglycemia [30]
[31]
[32]. With a carbohydrate
intake of about 50 EN % and the remaining distribution to fat and
protein, about 50% of the total insulin is distributed to the
fast-acting mealtime insulin and 50% is covered by the basal supply.
People with type 1 diabetes who have a low carb diet have a correspondingly
higher basal rate and a lower proportion of mealtime insulin. However, there
are situations in which low carbohydrates, high fat and protein are eaten
with the main meal or in which a high proportion of fat and protein is taken
in the evening via nuts, for example. In these cases, a simple bolus via
mealtime insulin is usually not sufficient. One way to cover the slow
glucose increase as a result of such meals would be, for example, a
correction with fast-acting mealtime insulin at a later time. With CSII
therapy, it would also be possible to give a delayed bolus. In order to know
how much bolus to give, the FPU (fat-protein unit) was propagated as a
measure.
According to Pankowska, 100 kcal of fat and protein are calculated as
one CU and, depending on the amount of FPU, are delivered as a delayed bolus
for a maximum of 8 h [30]
[33]. In practice and in various studies,
however, it has been observed that this formula cannot be used equally well
for all people with type 1 diabetes. In a paper by Hermann, a calculation
with 200 kcal corresponding to one CU was compared [34]. In this work it was confirmed that
hardly any formula can be applied equally well to everyone. In a pilot study
with nuts, the same result was also obtained [35]. Glucose increases can be observed after eating foods rich in
fat and protein, but the insulin dose must be determined and trained
individually. Increasing the prandial insulin dose for high-protein evening
meals increases the risk of night-time hypoglycemia.
Fiber and glycemic control
Recommendation
-
There is not yet sufficient evidence that people with type 1 diabetes
should eat a high-fiber diet to achieve their glycemic therapy
goal.
-
Possible effects of a fiber-rich diet on other health-promoting
aspects (e. g. cardiovascular diseases, intestinal health,
weight management) should be considered separately and
individually.
-
The increased consumption of high-fiber foods seems to have a
positive effect on the trend of postprandial glycemia, but the
recommendations for fiber intake are based on those for the general
population (30 g per day).
Comment
A fiber-rich diet is generally considered to be beneficial to health,
especially in the case of diabetes mellitus. The German Nutrition Society
(Deutsche Gesellschaft für Ernährung) recommends a daily
intake of at least 30 g of dietary fiber for the general population,
which is not achieved by the average German population [36]. So far, there are no evidence-based
recommendations for a certain amount of dietary fiber in diabetes. Although
many studies have been designed for type 2 diabetes, there is often no
explicit differentiation between diabetes types, although there are certain
aspects that require separate consideration [37].
In later life, for example, the study situation for high-fiber diets (DASH
diet, vegetarian, vegan) is inconsistent regarding, e. g., renal
endpoints, but there is a small indication to the benefits of vegetarian
diets in a systematic review [38]. Lower
blood pressure [39] and a lower
inflammatory load are positive outcomes of higher dietary fiber intake in
T1Dm [40].
In terms of weight management, dietary fiber plays a strong role, at least in
type 2 diabetes, when consumed as part of a diet that has a low glycemic
index [41]. Fiber contributes to a
reduction in energy density and a lowering of the glycemic index and
positively modulates the blood glucose profile. Observational studies in
subjects with T1Dm have also shown an association with lower
HbA1c levels, but the association was only mildly
significant, possibly explained by the suboptimal amount of dietary fiber
ingested (mean value 16 g fiber per day) [42].
To investigate the influence of the microbiota, prebiotics were used to
improve bacterial diversity. Inulin led to an increase in bifidobacteria in
young type 1 diabetes patients (<17 years) and simultaneously to a
higher C-peptide value than in the control group [43].
Supply of sucrose and fructose
Recommendation
-
Beyond general recommendations, there is no evidence of specific
recommendations for reducing added sucrose in individuals with
T1Dm.
-
Foods containing naturally-occurring sugars (glucose and fructose)
should not be restricted in the diet of people with type 1
diabetes.
-
The evidence base for the recommendation of a reduction of added
fructose is uncertain.
Comment
The evidence for adult individuals with T1Dm regarding recommendations for
sucrose and fructose intake is limited. With regard to the intake of added
sugar, current evidence-based guidelines generally recommend that people
with diabetes mellitus minimize their intake of added sugar and replace it
with foods with a higher nutrient density [4]
[6]
[7]. The majority of the European
professional societies express the recommendation to reduce the intake of
sugar (primarily free or added sugars) for the general population as well.
Recommendations that state a suggested upper limit usually set this at 10 EN
% for adults and 5 EN % for children>2 years [44]. However, according to the dietary
recommendations of the American Dietetic Association for people with T1Dm
and T2Dm, sucrose intake of 10–35 EN % has no negative
effects on glycemic or lipid response when sucrose isocalorically replaces
starch [45]. A similar conclusion, namely
that a sugar intake at a level common in human nutrition does not lead to
undesirable metabolic health effects, is drawn by Rippe et al. in their
review of randomized controlled trials [46].
In a randomized, controlled trial over the span of 3 months in which 33
persons with T1Dm received either a sucrose-free or a sucrose-enriched diet
(mean sucrose or fructose intake after the intervention: 2 vs. 27 EN
% or 6 vs. 9 EN %), it was also confirmed that although
higher concentrations of inflammatory markers (C-reactive protein) were
detectable in subjects with higher sucrose intake, the two groups did not
differ in insulin requirements, glycemic control, anthropometric parameters,
body composition, or triglyceride concentrations [47].
The intake of fructose with regard to diabetes mellitus is intensively
discussed due to its metabolization different to glucose. Since fructose
is first metabolized in the liver, it does not lead to an increase in
blood glucose levels, unlike glucose, and thus does not trigger the
release of insulin. Furthermore, fructose is converted to free fatty
acids during de novo lipogenesis, but only to a small proportion of
about 1–5% [48].
Systematic reviews and meta-analyses, which included individuals with
T1Dm, as well as a randomized controlled trial with T1Dm patients, show
lower postprandial peaks for blood glucose, lower total cholesterol
concentrations, no differences in other serum lipid parameters, but
possibly increased uric acid concentrations and oxidative stress in an
isocaloric comparison of fructose with other carbohydrates [49]
[50]
[51]
[52]. Due to the hepatic metabolization
of fructose, its influence on hepatic insulin sensitivity is also widely
discussed. The evidence for persons with and without T2Dm shows that
only a very large increase in fructose intake to approximately
80 g/d leads to a moderate reduction in hepatic insulin
sensitivity, without an accompanying clinically-significant increase in
fasting blood glucose concentrations [53].
In summary, the rationale for a reduction in sucrose and fructose intake for adults with
T1Dm due to a lack of evidence for this group of people is primarily derived from the
evidence for the general population or, more generally, people with diabetes and is
based on the recommendations of a balanced diet: although an isocaloric replacement of
foods containing sucrose or fructose with other carbohydrates may have similar effects
on blood glucose levels or other metabolic parameters, consumption should be minimized
in favor of foods with a higher nutrient density [54],
and the selected foods containing carbohydrates in the diet should ideally be rich in
fiber, vitamins, minerals and low in added sugars, fats and sodium [55].
For children and adolescents with T1Dm, the following study results can also be taken
into account to justify a reduction in sucrose and fructose intake: data from a review
and observational study show that a higher sugar intake is associated with the
development of T1Dm in childhood [56] and that the
late phase of disease development in particular could be accelerated [57]. In adolescents with manifest T1Dm, fructose intake
was directly associated with triglyceride concentrations [58]. However, the intake of naturally-occurring sugars (within the normal
range of the diet) was associated with improved parameters of glycemic control, and
Nansel et al. conclude that foods containing this source of sugar do not have negative
effects on blood glucose control in adolescents with T1Dm [59].
Use of sweeteners
Recommendation
Comment
The topic of “sweeteners” is a recurring topic of discussion
in nutrition. Sweeteners are synthetically produced or natural compounds
with a high sweetening intensity, which are metabolized independently of
insulin and are not cariogenic. Even though the calorie content of some
sweeteners is 4 kcal/g, just like conventional sugar
(sucrose), they are only used in very small amounts in the milligram range
due to their high sweetening power, so that calorie intake is negligible. As
additives, sweeteners are subject to a health assessment by the European
Food Safety Authority (EFSA) prior to approval, which determines acceptable
daily intakes (ADI). The ADI value indicates the amount of an additive that
can be ingested daily per kilogram of body weight over a lifetime without
causing health risks. Even after approval, the EFSA continues to further
investigate the sweeteners if necessary. Although sweeteners are therefore
considered to be harmless to health according to the current state of
knowledge, possible long-term health consequences in particular have been
discussed repeatedly for many years.
The reservation of an increased cancer risk from sweeteners is mainly based
on older studies, which are based on results from animal experiments.
However, these studies used very high amounts of the sweetener in question,
far in excess of the acceptable daily intake for humans, so the results are
not transferable to humans. According to recent animal studies and available
human data, there is no evidence of an increased cancer risk from sweeteners
if the ADI values are adhered to [60]
[61].
An increase in weight caused by sweeteners has not yet been scientifically
proven. The clinical studies on this topic sometimes diverge considerably.
Epidemiological studies predominantly conclude that sweetener consumption is
associated with an increased risk of excess weight or obesity. By contrast,
studies with higher evidence levels tend to indicate a weight-neutral effect
or that sweeteners are a tool that can be used with limitations for reducing
energy intake and weight control [62]
[63].
Some observational studies show a positive association between sweetener
consumption and the risk of type 2 diabetes and other cardiometabolic
diseases, but the bias of excess weight and reverse causality is often a
problem [61]
[63]
[64].
Regarding the effect of sweeteners on appetite, intervention studies show
that beverages containing sweeteners have an effect similar to water on
appetite and energy intake [63]
[65]
[66].
A recent review of various studies investigating the effect of sweeteners on
the appetite and consumption of sweetened products also showed no increase
in either appetite or consumption [67].
With regard to the effects on human intestinal microbiota, the data is
limited and does not provide sufficient evidence that sweeteners at the
levels relevant for human consumption have a negative impact on the
microbiota [63]
[68].
The potential benefit of sweeteners in patients with type 1 diabetes is
mainly due to their use as a substitute for sugar without triggering a
glycemic response. Despite controversial discussions, current research
provides collective evidence that the consumption of sweeteners has no
adverse effects on blood glucose and insulin regulation (HbA1c,
fasting and postprandial glucose and insulin levels) in people with and
without diabetes [63]
[69].
In general, research on sweeteners is hampered by the chemical and metabolic
heterogeneity of sweeteners, their, at times, combined use in different
product groups and the changing trends in consumer behavior [61]
[70].
Effective blood glucose food for hypoglycemia
Recommendation
-
Persons with T1Dm and mild hypoglycemia (can be treated by the
patient) should consume 15–20 g of rapidly
absorbable carbohydrates. This measure should be repeated after
15 min if blood glucose concentrations remain low.
-
Persons with T1Dm and severe hypoglycemia experiencing confusion or
clouding of consciousness should consume 30 g of rapidly
absorbable carbohydrates. In individual cases, it may be necessary
to supplement with 15–20 g of slowly resorbable
carbohydrates.
Comment
Rapid carbohydrates such as oral glucose in solid and liquid form are
particularly suitable for treating hypoglycemia. Furthermore,
sucrose-containing beverages such as lemonades and juices can be used.
In some cases, slowly resorbable carbohydrates can contribute to the
stabilization of blood glucose depending on the situation [6]
[7]
[8].
In order to preventatively avoid hypoglycemia, in special situations, rapidly
resorbable carbohydrates should be ingested beforehand to increase the
target value and slowly resorbable carbohydrates should be supplemented to
stabilize the trend. The amount should be chosen individually and depend on
the situation. Classic situations that can result in hypoglycemia are
physical activity and alcohol consumption [6].
People who suffer from severe hypoglycemia, who can no longer undergo
self-therapy or who are unconscious should not be given oral carbohydrates.
In these cases, treatment with glucagon by family members or relatives is
possible or professional IV glucose administration. Friends and family
members should be trained in the use of glucagon kits [71].
General nutrition aspects
General nutrition aspects
Protein consumption
Recommendation
Comment
Increased protein intake has been scientifically studied in people
with type 1 diabetes mellitus, particularly with regard to the acute
glycemic response [72]. In this context,
reference is made to the recommendation on “Insulin requirements for
protein and fat-rich meals”.
No evidence has been shown that increased protein intake leads to positive or
negative effects in people with type 1 diabetes.
A limitation of protein intake has been studied, especially with
regard to slowing the progression of diabetic nephropathy.
In general, RCT with intervention times>6 months show that protein
targets<0.8 g/kg body weight/d are rarely
met even under study conditions.
In a larger randomized controlled trial, a low-protein diet in people with
type 1 or 2 diabetes and nephropathy achieved significant improvements in
GFR when compliance was good [73].
In another methodologically well-conducted study, limited protein intake also
appeared to slow the progression of diabetic nephropathy, but the effects
were not significant. Compliance was also poor in this study and difficult
for patients to maintain. Another study showed no difference in the rate of
progression of diabetic nephropathy with low normal protein intake
(0.8 g/kg body weight, 16 EN %) vs. high normal
protein intake (19 EN %) [74].
In summary, the evidence for a recommendation for protein reduction –
even in diabetic nephropathy – is insufficient. In individual
situations and taking into account a high biological value of the proteins,
a mild protein restriction may be justified with the aim of inhibiting the
progression of diabetic nephropathy. However, this should always be
accompanied by professional nutritional advice, since there is a risk of
malnutrition especially in advanced stages of renal insufficiency.
General Nutrition Aspects
General Nutrition Aspects
Fat intake
Recommendation
-
No specific recommendation can be made for the amount of fat intake
in people with T1Dm.
-
Effects of the fatty acid composition (fat quality) on other
health-promoting aspects may need to be considered separately.
However, the fat quality should be in accordance with the
recommendations for the general population.
Comment
For the acute blood glucose response after fat intake, please refer to the
chapter “Insulin requirements for protein and fat-rich
meals”.
The popularity of low-carbohydrate and thus mostly high-fat diets is high.
However, high-fat and low-carbohydrate diets have not been well studied in
the treatment of type 1 diabetes. Studies that looked at glycemic outcomes
from low-carbohydrate diets were mostly cross-sectional studies without
validated nutritional data and without control groups. Participants were
highly motivated, self-selected individuals who used intensive insulin
management practices, including frequent blood glucose monitoring and
additional insulin correction with narrow glycemic targets. Therefore, these
results are not necessarily transferable to patients with type 1 diabetes in
general. Carbohydrate-containing foods such as cereals, fruits and milk are
important sources of nutrients. Therefore, low-carbohydrate diets require
attention to vitamin and energy intake to avoid micronutrient deficiencies
and growth problems in children. Following restrictive diets is a challenge
and can affect social normality. People with type 1 diabetes also
theoretically have adverse health risks such as diabetic ketoacidosis,
hypoglycemia, dyslipidemia and glycogen deficiency [75].
In general, observational studies often associate high fat and low
carbohydrate intake with higher BMI [76],
but this does not allow the conclusion to be drawn that low fat and high
carbohydrate intake is generally recommended. Observational studies often do
not address the quality of the fats and carbohydrates ingested, so that it
is not taken into account that too many low-value fats and too few complex
carbohydrates are usually ingested (see also DDG statement on ADA
Recommendations 2019 [5]).
Rather, randomized, controlled intervention studies evaluating the quality of
macronutrients should be considered to answer the question of modifying fat
intake for people with type 1 diabetes.
Eating Patterns
Recommendation
Comment
According to the recommendations of the American, Canadian, and British diabetes
associations, there are a variety of dietary patterns that are suitable for
people with diabetes. For example, a diet based on the Mediterranean diet or the
Dietary Approaches to Stop Hypertension (DASH) diet could help improve glucose
metabolism and weight control and reduce cardiovascular risk factors. However,
low-carbohydrate, vegan/vegetarian, plant-based diets, or a diet rich in
legumes could also be suitable for people with diabetes. Individual preferences,
goals and needs should influence the choice of dietary pattern [6]
[7]
[8]. Even specifically for people with T1Dm, the
American Diabetes Association says that there is insufficient evidence to make
one dietary pattern more recommendable than another [6].
Further evidence from intervention and observational studies for individuals with
T1Dm is available on the Mediterranean diet, the DASH diet, the Healthy Eating
Index (HEI) or Alternative Healthy Eating Index (AHEI) and the Whole Plant Food
Density (WPFD) score. In a cohort study of 118 adults with T1Dm, a Mediterranean
diet was associated with a favorable cardiometabolic profile [77], whereas a 6-month intervention study of 28
adults with T1Dm and metabolic syndrome showed no superiority of a Mediterranean
vs. low-fat diet in terms of anthropometric and metabolic parameters [78]. In 96 children and adolescents with T1Dm,
structured nutritional training for a Mediterranean diet improved the quality of
nutrient intake, followed by an improvement in serum lipid levels [79]. In a 5-year longitudinal observational
study of 500 children and adolescents with T1Dm, greater adherence to the
Mediterranean diet was also associated with better glycemic control and better
serum lipid levels [80].
In the SEARCH for Diabetes in Youth Study, it was observed in 2 cross-sectional
analyses of 2440 and 1810 adolescents with T1Dm that greater adherence to the
DASH diet is inversely associated with hypertension, HbA1c levels and
the LDL-HDL ratio [81]
[82]. However, in a preliminary controlled
intervention study in 16 adolescents with T1Dm, participants on the DASH diet
were shown to have increased glycemic variability compared to their usual diet.
Adapting the DASH diet to people with diabetes (e. g., 30 EN %
from fat instead of 20 EN %) resulted in a glycemic variability
comparable to the usual diet, but with lower average blood glucose
concentrations and less time in the hyperglycemic range [83].
The role of HEI, an index measuring compliance with U.S. dietary recommendations,
was investigated in 4 observational studies in children and adolescents with
T1Dm. The studies showed conflicting results regarding the association between
the HEI and glycemic control, and no association between the HEI and
cardiovascular biomarkers [84]
[85]
[86]. In
an observational study of 12 subjects with T1Dm and 75 subjects with T2Dm (no
stratified analysis), greater adherence to the alternate healthy eating
index (AHEI) was prospectively associated with improved vascular health [87].
Two cross-sectional studies in adolescents with T1Dm showed that neither the
Mediterranean diet, the DASH diet, nor the HEI was associated with selected
biomarkers of inflammation, and that only the HEI was inversely related to
microalbuminuria, which was no longer significant after adjustment for
HbA1c and systolic blood pressure [88]
[89].
Greater adherence to whole grains, fruits, vegetables, legumes, nuts, and seeds
was associated with better glycemic control in a longitudinal observational
study in adolescents with T1Dm [72].
In addition to the evidence for the above described hypothesis-based dietary
patterns, 4 cross-sectional and one longitudinal observational study
investigated associations between exploratory dietary patterns and metabolic
parameters such as glycemic control and blood pressure, inflammatory biomarkers,
serum lipid levels, and vascular health parameters in subjects with T1Dm [90]
[91]
[92]
[93]
[94]. These studies also confirm the conclusion
of medical societies that there are a variety of dietary patterns that may be
beneficial for people with diabetes, in this case T1Dm [6]
[7]
[8].
Meal frequency and meal timing
Meal frequency and meal timing
Recommendation
-
If people with T1Dm are overweight, they should avoid irregular eating
times, eating late and a time window for daily food
intake>12 h. Instead, they should consume the calories
predominantly in the first half of the day, as this can have a
beneficial effect on body weight regulation and cardiometabolic
risk.
-
A recommendation for fasting during the day (<3 meals per day) or
modified intermittent fasting on one or more days a week cannot be
given.
Comment
Irregular food intake, such as skipping meals and snacking behavior, where small
portions are often eaten between meals and almost around the clock, is a
characteristic of the modern lifestyle [138].
To investigate the influence of frequency and timing of food intake on energy
balance and cardiometabolic risk, studies in healthy individuals and subjects
with high metabolic and cardiovascular risk are considered below.
A high meal frequency could increase the risk of obesity [139]
[140], as
many small meals lead to less satiety than 3 larger meals with the same energy
intake [141]
[142]. In addition, frequent smalls meals compared to fewer meals with
the same energy intake resulted in higher liver fat content [142]
[143].
On the other hand, lower meal frequency, lower caloric intake at breakfast or
complete skipping of breakfast was associated with higher weight gain and
increased risk of diabetes, heart attack and stroke in prospective long-term
studies [144]. Intervention studies of varying
durations provide further evidence that skipping breakfast and/or lunch
does not have consistently positive effects on body weight regulation or glucose
metabolism [138]
[145], [146]
[148]
[148]. In
contrast, skipping the evening meal and eating three meals by early afternoon
resulted in improved insulin sensitivity, ß-cell response, blood
pressure, and appetite compared to an isocaloric breakfast, lunch, and dinner
protocol [149]
[150].
The influence of the time of mealtime intake on body weight and cardiovascular
and metabolic risk is partly explained by circadian differences in metabolism
(e. g. with regard to insulin sensitivity). On the other hand, the
circadian clock, with the help of clock genes and clock-controlled genes, uses
food intake as a timer, so the timing of meals can have an influence on the
energy balance and metabolic risk [151]. If
food is consumed mainly in the evening or at night, contrary to the natural
circadian rhythms, e. g. by skipping breakfast, this leads to lower
postprandial thermogenesis and higher postprandial glycemia and insulin response
[152]. Consuming low GI foods in the
morning leads to a greater improvement in glycemia than consuming them in the
evening [153].
In addition, a long daily time window in which energy is ingested, independent of
the time of food intake, promotes weight gain [138]. A reduction of the daily time window during which food was
eaten from more than 14 h to 10–12 h led to weight loss
with an otherwise unchanged diet [154].
Intermittent fasting is a popular concept for weight loss based on major cycles
of dietary restriction, which do not involve skipping a single meal, but instead
provide a greatly reduced calorie intake (0 to<25% of energy
requirements) every 2nd day or 2–3 times a week. Intermittent fasting
results in significant weight loss depending on the frequency of the fasting
days, but this is no different from the success of a reduction diet with
continuous energy restriction [155]
[157]
[158]
[158]. The effects of this
negative energy balance lead to a differently pronounced reduction of
cardiometabolic risk factors depending on the level of the initial values.
There are worries that intermittent fasting increases the variability of glycemia
by increasing the risk of both hypoglycemia and postprandial hyperglycemia [159], [160].
The lack of superiority of intermittent fasting over continuous, moderate
calorie restriction and the lack of studies on the risks and long-term results
in subjects with T1Dm make a recommendation for intermittent fasting
impossible.
Recommendations for body weight
Recommendations for body weight
Recommendation
-
People with T1Dm and normal weight should maintain a normal body
weight.
-
The study situation is not sufficient to generalize the recommendation
for weight reduction to people with type 1 diabetes and excess weight.
However, the recommendation for weight reduction may be useful in the
presence of concomitant diseases or insulin resistance (e. g.
secondary dyslipoproteinemia, high blood pressure, steatohepatitis,
etc.).
-
The quality of food and possible hypoglycemia should be considered,
especially in low-carb diets. This may also result in eating
disorders.
Comment
A higher BMI is associated with macrovascular disease and retinopathy in type 1
diabetes [6]
[7]. There are no evidence-based studies showing an association
between weight and glycemic control in type 1 diabetes. However, it can be
assumed that weight loss in type 1 diabetes with simultaneous insulin resistance
or parallel metabolic syndrome has similar effects to type 2 diabetes [78]
[83]
[154].
Therefore, weight reduction in obese T1Dm patients is likely to be beneficial in
a diet with a low caloric density but high nutritional quality, especially if
the aim is to predominantly reduce abdominal fat.
Very-low-carb diets, formula diets or interval fasting may increase the risk of
hypoglycemia and should be used only with close adjustment of the insulin
regimen and discussed with the diabetes team.
There is no scientific evidence for the superiority of a nutritional concept
(e. g. low-carb or low-fat) in terms of weight loss for T1Dm. Regarding
meal frequency, please refer to the text section “Meal Frequency and
Meal Timing”.
Particularly with the somewhat younger T1Dm patients, the patient desire for
weight reduction must be critically weighed against the risk of developing or
succumbing to an eating disorder. Female patients are particularly vulnerable
compared to male T1Dm patients, [161]. A
survey of 34 normal and overweight T1Dm patients showed that weight management
and metabolic control measures often contradict each other. This can result in
conflict potential and incompliance [162].
Bariatric surgery as a method for weight reduction in patients with T1Dm is to be
evaluated critically and must be coordinated with the obesity team and the
diabetes team on a case-by-case basis.
Weight reduction in obese T1Dm patients as a side effect of a generally
metabolically-beneficial diet is likely justifiable, especially if predominantly
visceral fat deposits are to be reduced. However, there is insufficient data on
this. Very-low-carb diets or interval fasting can increase the risk of
hypoglycemia and should therefore only be used with close adaptation of the
insulin regimen.
One study compared a weight loss diet high carb/high fat versus high
carb/low fat, with no difference in HbA1c
[183].
Observational studies or studies with small numbers of test persons on the
consumption of unsaturated fatty acids, n-9 fatty acids or olive oil have
not yet provided a reliable basis for recommendations.
In a Spanish observational study, uptake of PUFAs/SFAs>0.4
and MUFAs/SFAs>1.5 was associated with near-optimal
metabolic control goals and a reduction in the risk of diabetic
complications [184].
This is supported by another RCT that showed that increased uptake of MUFAs
leads to improved glycaemia. A 10% increase in n-9 RCFAs was
associated with a 0.64% improvement in HbA1c
[185]. Correspondingly, an RCT showed that
acute glycemia was more favorable after olive oil than after butter [186].
Dietary recommendations for weight maintenance
Dietary recommendations for weight maintenance
Recommendation
Comment
Studies on the optimal diet for weight maintenance at T1Dm are not available. The
recommendations should be based on the DGE guidelines for healthy individuals,
but without defining a specific proportion of macronutrients.
Nutritional intervention studies without weight loss differed in the metabolic
outcome. With Mediterranean diet (n=96) the lipid profile improved, with
low-fat diet (n=10) insulin sensitivity in T1Dm patients was also
reduced [163].
In individual cases and when used in moderation, carbohydrate reduction can be
safe and with few side effects but without particular benefit (Case Report)
[171]. However, the risk of hypoglycemia
is increased when short-acting insulins are used with “low carb”
[172]. In contrast, other studies also
show a reduction in the risk of hypoglycemia with even a severe reduction in
carbohydrates (<50 g; n=10, 1 week). Ketonuria as an
indicator of insulin deficiency is limited [173]. The effectiveness of emergency glucagon is also reduced due to
the lower liver glycogen content [169].
Diets rich in carbohydrates are without advantage or disadvantage when the
insulin dose is adjusted (n=9, 4 weeks) [174], lower insulin requirements are necessary in the case of a
high-fiber variant (n=10, 4 weeks) [175], but on the other hand can be associated with a worsening of the
metabolic situation – even during intense physical activity
(n=7, 3 weeks) [176].
Qualitative differences of carbohydrates influence the glucose increase for T1Dm.
Complex carbohydrates should be used to optimize therapy (n=12, one-time
acute test of rice vs. pasta varieties) [177].
However, the benefit of a glycemic diet is limited (n=11; 12 weeks, no
control group) [178]. As in healthy
individuals and T2Dm, soluble dietary fiber (e. g. guar) does not show
the long-term benefit in terms of glycemic control (n=8; 4 months) but
is still recommended as a component of natural foods for other metabolic reasons
[179].
Short-term interventions with the aim of avoiding weight gain, e. g. via
VLCD days or short-term intermittent fasting (8:16), require individual
continuous glycemic control in order to ensure or optimize the suitability of
the applied insulin dosing strategy for such days.
Nutritional aspects in geriatric patients
Nutritional aspects in geriatric patients
Recommendation
-
There are no special dietary recommendations for elderly or geriatric
persons with T1Dm.
-
The goals in nutrition therapy often have a different focus and focus on
maintaining independence more than the actual glycemia and, in geriatric
patients, on avoiding malnutrition and hypoglycemia.
-
The recommendations of a protein intake that meets the needs (at least
1 g/kg body weight/d) and the maintenance of a
BMI that is up to slightly overweight are basic measures that correspond
to the recommendations for the general population and also apply to this
group of people.
Comment
Basically, the nutritional recommendations for older people with T1Dm do not
differ from those for older metabolically healthy or younger people with T1Dm.
At the same time, the general nutritional recommendations for geriatric patients
apply to geriatric patients with T1Dm. Especially in functionally-dependent
patients, the consequences of malnutrition in old age are severe and should be
focused on in patients with T1Dm. For example, the loss of muscle mass
associated with weight loss reinforces the age-related sarcopenia and frailty,
thereby promoting disabilities and loss of independence.
The S2k guideline “Diagnosis, therapy and follow-up of diabetes in old
age” also contains very detailed recommendations for the general
nutritional therapy of elderly people with diabetes. It makes it clear that
therapeutic goals – also with regard to nutrition – can, but
need not, often change in older and especially geriatric patients. Functionality
and the preservation of independence are in the foreground.
Although an improvement in insulin sensitivity could also be achieved in older
people through an intended weight reduction [180], strict dietary restrictions should be avoided in older people
who are overweight or obese due to the risk of malnutrition. Dietary
restrictions that may limit food intake are potentially harmful and should be
avoided. If weight loss is being considered, dietary measures should be combined
with physical activity whenever possible, and the focus should be on protein
intake to meet the needs. A significant increase in mortality was only found in
people over 65 years of age when their body mass index (BMI) exceeded 30 [180]. Restrictions in the consumption of
familiar and comfort food lead to a reduction in the subjectively-perceived
quality of life. This aspect is particularly important for people in old
age.
The risk of potential malnutrition is present if the reduced food intake
continues (approximately<50% of the requirement for more than 3
days) or if several risk factors are present at the same time, which either
reduce the amount of food or significantly increase the energy and nutrient
requirements. The risk of malnutrition can be assessed e. g. by MNA or
the corresponding short form (SF-MNA), both screening methods are well evaluated
[181]
[182]. In underweight patients, the causes should be clarified and, if
possible, eliminated.
Nutritional therapy should also focus on the prevention of hypoglycemia, with an
initial focus on the adjustment of medication.
For further information, especially for persons with diabetes in nursing homes
and if artificial nutrition is necessary, please refer to the S2k guideline
“Diagnosis, therapy and follow-up of diabetes in old age” and
the S3 guideline “Clinical nutrition in geriatrics” (DDG 2018,
DGEM 2013).
Due to the complexity of the often multimorbid geriatric patients, planning and
implementation of disease-specific diets should, if necessary, be carried out by
a multi-professional team including a nutritional expert.
Nutritional aspects of special foods and nutritional supplements
Nutritional aspects of special foods and nutritional supplements
Sugar-sweetened beverages
Recommendation
Comment
Similar to the evidence for sucrose and fructose intake in people with T1Dm,
the data on the intake of sugar-sweetened beverages specifically for this
group of patients is also limited, so that recommendations made for the
general population and for people with diabetes in general must also be
used. According to the current evidence-based guideline of the American
Diabetes Association, the intake of sugar-sweetened beverages is strongly
discouraged for people with diabetes, and water is recommended as often as
possible to control blood glucose levels and body weight, and reduce the
risk of cardiovascular disease and fatty liver (evidence level B) [4]
[6].
The British Diabetes Society rates the evidence on reducing the intake of
sugar-sweetened drinks as low but agrees that reducing the consumption of
sugar-sweetened drinks reduces cardiovascular risk (Grade 2) [7].
For the general population, a low intake of sugar-sweetened beverages is
recommended, among other things, because of their high energy content and
the resulting risk of obesity. Limiting their intake is recommended because
it contributes to an increased micronutrient density and reduced sugar
intake [95]. Minimizing their intake and
replacing them with water or unsweetened milk or dairy products is also
recommended specifically for children and adolescents, regardless of their
diabetes status [95]. According to the
American Heart Association, the maximum amount for this age group should be
around 237 ml per week [95].
For persons with T1Dm, data for children and adolescents is available from 2
observational studies. The Diabetes Autoimmunity Study in the Young observed
1839 children and adolescents with an increased genetic risk for T1Dm over a
mean duration of 10.2 years. In study participants with a high-risk HLA
genotype, but not in those with a low or medium risk for T1Dm, the
progression from islet autoimmunity to T1Dm was associated with an increased
intake of sugar-sweetened beverages [96].
Based on cross-sectional analysis of the SEARCH for Diabetes in Youth Study,
it was shown that in children and adolescents with manifest T1Dm, a higher
(at least one serving per day) intake of sugar-sweetened beverages was
associated with higher levels of total cholesterol, LDL cholesterol and
plasma triglycerides, compared to no intake of sugar-sweetened beverages.
However, these associations were partially explained by an adjustment for
BMI, saturated fat and fiber intake. No association was found between the
intake of sugar-sweetened beverages and HbA1c, blood pressure,
and HDL cholesterol [97]
[98]. A high intake of sugar-sweetened
beverages may therefore have a negative effect on the cardiovascular risk
profile in children and adolescents with T1Dm and they should be encouraged
to minimize their intake [97].
Alcohol
Recommendation
-
People with T1Dm should limit the amount of alcohol consumed to the
amounts recommended for the general population. Moderate, low-risk
alcohol consumption is compatible with good metabolic control and
diabetes prognosis.
-
People with diabetes with risky alcohol consumption or an alcohol
dependency should be informed about the dangers of alcohol,
especially with regard to poorer metabolic control and the risk of
secondary diseases.
-
It should generally be noted that consumption of larger amounts of
alcohol increases the risk of severe hypoglycemia, especially at
night. This risk is reduced by eating during the period of alcohol
consumption and raising the target blood glucose level into the
night.
Comment
People with diabetes should be advised of the effects of alcohol consumption
on blood glucose levels and, if alcohol is consumed, should be encouraged to
stick to low-risk consumption amounts. The German Head Office for Addiction
Issues e. V. (Deutsche Hauptstelle für Suchtfragen e. V. –
DHS) specifies 12 g alcohol per day for women and 24 g
alcohol per day for men as limits for low-risk consumption. The World Health
Organization (WHO) defines a consumption of 10 g alcohol per day for
women and 20 g alcohol per day for men as low-risk. These amounts
also apply to people with type 1 diabetes.
The consumption of alcohol can affect blood glucose counterregulation and
thus increase the risk of hypoglycemia. About one in five cases of severe
hypoglycemia leading to hospitalization is caused by alcohol consumption.
However, the main effect of alcohol is likely to be reduced awareness, which
leads to a limited perception of hypoglycemia and prevents those affected
from reacting appropriately. A systematic review on this issue is available
from 2018 [187]. A total of 13 studies
(RCT and observational studies) were evaluated.
Eight studies reported that ethanol – regardless of whether
administered intravenously or orally – was associated with an
increased risk of hypoglycemia, which was linked with a decrease in plasma
glucose, an impaired counterregulatory response, hypoglycemia perception
disorder, and impaired cognitive function.
Five studies could not prove an increased risk of hypoglycemia. None of the
studies investigated prevention strategies for ethanol-induced hypoglycemia.
Recommendations from 13 diabetes associations were included. All
associations recommend only consuming ethanol together with food. The
majority of the included studies showed that ethanol consumption increased
the risk of hypoglycemia in patients with T1D. However, the evidence for the
prevention of ethanol-induced hypoglycemia is scarce and further
investigation is needed to provide evidence-based recommendations.
Excessive consumption of alcohol interferes with diabetes therapy. Patients
with excessive or risky alcohol consumption are less likely to implement
therapy recommendations on exercise, diet, medication, blood glucose
self-monitoring or regular HbA1c monitoring. There is a linear
relationship: the higher the drinking volume, the less frequently therapy
recommendations are implemented.
According to the S2k guideline “Psychosocial factors and
diabetes”, people with diabetes should be surveyed regularly
– at least once a year – for their alcohol consumption, and
help should be offered to patients with risky alcohol consumption.
Nutritional supplements
Recommendation
Comment
The American and Canadian diabetes associations summarize the evidence on
nutritional supplements in general for people with diabetes as follows:
There is no clear evidence that supplementation with vitamins, minerals
(e. g., chromium or vitamin D), herbs or spices (e. g.,
cinnamon or aloe vera) improves metabolic control in people without
underlying nutritional deficiencies, and it is not generally recommended to
improve glycemic control. Routine supplementation with antioxidants
(e. g. vitamin E, C or carotene) is not recommended due to a lack of
evidence of efficacy and long-term safety concerns. However, multivitamin
supplementation may be necessary in special groups such as pregnant or
lactating women, elderly individuals, vegetarians or people on an extremely
low-calorie or low-carbohydrate diet [6].
Instead of the general recommendation of routine nutritional
supplementation, people with diabetes should be encouraged to meet their
nutritional needs through a balanced diet [8].
There is scientific evidence for supplementation with vitamin D,
polyunsaturated fatty acids (PUFAs), chromium, zinc, magnesium, and iron
especially for people with T1Dm.
For supplementation with PUFAs, a systematic review and meta-analysis
summarizes data from 7 observational studies in subjects with preclinical
and clinical T1Dm [100]. The evidence that
PUFAs protect against preclinical T1Dm was classified as
“low” when interventions were combined both during pregnancy
and early childhood. However, a sub-analysis based on one study showed that
supplementation with n-3 PUFAs in infancy could reduce the risk of
preclinical T1Dm. Supplementation with PUFAs was not associated with a risk
reduction for clinical T1Dm in children [100].
A cohort study based on 59 children with newly-manifested T1Dm and
investigating the effects of a 12-month co-supplementation of n-3 PUFAs and
vitamin D showed an improvement of surrogate parameters of endogenous
insulin secretion in the group of co-supplemented children vs. children
supplemented only with vitamin D in a reduction of the nutritive intake of
arachidonic acid against the background of a Mediterranean diet [101].
In people with T1Dm, vitamin D is the most commonly studied nutritional
supplement. Serum concentrations of vitamin D are lower in patients with
T1Dm than in controls, but it is still unclear whether vitamin D deficiency
is a trigger or consequence of autoimmune disease [102]
[103]. The effects of vitamin D supplementation on the risk of T1Dm in
young children have been investigated in 2 meta-analyses and one review,
which partly overlap in the included studies [103]
[104]
[105]. There are insufficient studies on
whether prenatal supplementation with vitamin D influences the risk of T1Dm
later in life [103]
[104]. Observational studies suggest that
administration of vitamin D during infancy seems to be associated with a
reduced risk of T1Dm [103]
[104]
[105]. A dose-response relationship could be subject to this
relationship: a higher vitamin D intake is associated with a lower risk of
T1Dm, and the timing of supplementation could also be critical, a lower risk
of T1Dm was found at 7–12 months vs. 0 and 6 months of
supplementation [105]. Two observational
studies also suggest that vitamin D administration in young adults may have
a protective effect on the risk of T1Dm [103]. The evidence from intervention studies and randomized
controlled trials on the effect of vitamin D supplementation for the
treatment of manifest T1Dm is summarized in one systematic review and two
additional reviews. Even after that, the results are contradictory, and
vitamin D supplementation only shows a protective effect on β-cell
function and glycemic control in some studies [103]
[106]
[107]. With regard to vitamin D, the current
recommendation may be that people with a high genetic risk for T1Dm should
avoid vitamin D deficiency by adequate supplementation, but the evidence for
the administration of higher doses of vitamin D is insufficient [106].
In a case-cohort study of 257 children with T1Dm, the question was
investigated whether iron supplementation during pregnancy and the first 18
months of life is associated with an increased risk of T1Dm in childhood. It
was concluded that maternal supplementation with iron is not associated with
the risk of T1Dm, but that infantile supplementation shows an inverse
association with the risk of T1Dm [108].
Serum concentrations of the trace elements chromium, zinc and magnesium are
lower in persons with T1Dm compared to control persons. Observational
studies show correlations between lower serum concentrations of these trace
elements and poorer glycemic control in subjects with T1Dm, so
supplementation may help improve metabolic control. However, further studies
are needed to formulate a clear recommendation [109]. For the trace element zinc, a further systematic review, a
meta-analysis, and a review were identified. The former comprises 25
studies, 3 of them with subjects with T1Dm. The 2 case-control studies show
an increased zinc concentration in erythrocytes as well as reduced lipid
peroxidation after zinc supplementation, and the randomized, double-blind
study demonstrates an effect of zinc supplementation on lipid metabolism
[110]. A review describes zinc
supplementation as a possible measure to improve blood glucose control and
lipid metabolism in individuals with T1Dm, but points to the need for
further studies due to the conflicting results of existing human studies
[111].
In summary, the evidence on the use of nutritional supplements in persons
with T1Dm is heterogeneous and insufficient. The American and Canadian
medical societies do not make a general recommendation on the use of
nutritional supplements to improve metabolic control. Only compensating a
nutritive vitamin D deficiency in persons with a high genetic risk for T1Dm
could minimize this risk. A balanced diet generally provides an adequate
supply of micronutrients.
Probiotics
Recommendation
Comment
In Germany, probiotics are specified as “defined living
microorganisms which enter the intestine in an active form in sufficient
quantity and achieve positive health effects” [112].
The Lactobacillus and Bifidobacterium genera are mainly used
for the formulation in probiotics. Furthermore, specific lactic
acid-producing species of other genera are used, e. g.
Enterococcus faecalis, Streptococcus thermophilus or probiotic
yeasts (Saccharomyces boulardii). The dose varies between
108 and 1011 colony forming units, and the use of
the above genera or species is considered safe [113].
Probiotics are classified as nutritional supplements in Germany. The
manufacturers are legally free to decide on the dose, strains used or any
combination (multi-strain preparations) as well as possible additives
(vitamins, prebiotics, etc.). Health claims or claims referring to the
reduction of a disease risk are not permitted for probiotics, except for the
improvement of lactose intolerance and the reduction of infections (EC
1924/2006).
The intestinal microbiome and the immune system are closely intertwined [114]. The immunomodulating effect of the
intestinal microbiota or its metabolites, such as short-chain fatty acids,
especially butyrate, is shown, among other things, by their effect on
regulatory T cells [115]
[116], the inflammatory status [115], and the function of the intestinal
barrier [117]. In several studies of
volunteers with diagnosed type 1 diabetes, microbial diversity was found to
be lower than in healthy volunteers [118]
[119]
[120]. In the period immediately before or
at the onset of beta-cell autoimmunity, a higher proportion of
Bacteroides was repeatedly observed in the subjects compared to
the control group [121]
[122]
[123]
[124]. The
lipopolysaccharide (LPS) produced by Bacteroides showed an
immunosuppressive effect (measured by TLR4 and NF-κB activity) in
children prone to autoimmune disease [125]. Current studies also suggest an association between reduced
production of short-chain fatty acids, especially butyrate, by the
microbiome, and an increased risk of type 1 diabetes [118]
[124]
[125]. This leads to the
hypothesis that intestinal microbial disorders are associated with the
pathogenesis of beta-cell autoimmunity and type 1 diabetes mellitus [127]
[128].
To test the preventive effect of probiotics on the development of beta-cell
autoimmunity, studies were conducted in genetically predisposed children
before the onset of autoimmunity, primarily in infancy and early childhood
[129]
[130]. In the prospective, longitudinal, multicenter cohort
“Environmental Determinants of Diabetes in the Young”
(TEDDY), probiotic intake pre- and postnatally was assessed in 7473
infants/children with genetic predisposition to type 1 diabetes.
Early infant (0–27 days postnatal) probiotic intake may reduce the
risk of beta-cell autoimmunity in children with high-risk genotype
(HLA-DR3/4) [129]. On the other
hand, in a double-blind, randomized, controlled trial, the administration of
probiotics in infancy could not be associated with the development of
beta-cell autoimmunity [130].
In addition to preventive research on beta-cell autoimmunity, there are also
studies on the effects of probiotics in already manifest type 1 diabetes. An
eight-week supplementation of synbiotics (Lactobacillus sporogenes
GBI-30 with maltodextrin and fructooligosaccharides) in 50 subjects
(4–18 years old) with diagnosed type 1 diabetes resulted in an
improvement in fasting blood glucose, HbA1c, hs-CRP and TAC
(total antioxidant capacity) [188].
Another intervention study was conducted to determine whether a three-month
supplementation with Lactobacillus rhamnosus GG leads to an increased
immune function in type 1 diabetes patients following an influenza
vaccination. No improvement in the humoral immune response was observed, but
an anti-inflammatory effect was induced by supplementation [133].
The following points must also be considered when supplementing with
probiotics: on the one hand, probiotics can exhibit antibiotic resistance in
mobile genetic elements that can be transferred to other, possibly
pathogenic bacteria through interbacterial exchange [134]. The investigation of various
commercially-available probiotics showed that the probiotic bacteria tested
were resistant to several different broad-spectrum antibiotics [135]. On the other hand, in rare cases, a
weakened intestinal barrier function in critically-ill patients can lead to
a translocation of the supplemented microorganisms [136]. In addition, possible side effects
are not recorded in many studies in which the use of probiotics is
tested.
Finding a causal relationship between intestinal microbiota and the
pathogenesis of beta-cell autoimmunity is proving difficult. On the one
hand, this is due to the high heterogeneity of the genera or species of
probiotics used, the study populations as well as the study parameters; on
the other hand, to the individuality and complexity of the microbiome. New
findings also show that the administration of probiotics can significantly
influence the efficacy of a probiotic by making it resistant to colonization
by individuals, strains and regions, depending on the indigenous microbiome
[137]. Overall, there is evidence to
suggest that probiotic intake may be helpful in the prevention or therapy of
islet autoimmunity and type 1 diabetes. However, in the current study
situation, no recommendation can yet be made for taking probiotics for the
prevention or therapy of type 1 diabetes mellitus.