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Recommendations Summary

PDM: Nutrition Prescription for Macronutrients 2014

Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.


  • Recommendation(s)

    PDM: Nutrition Prescription for Macronutrients

    The registered dietitian nutritionist (RDN) should individualize the nutrition prescription for macronutrients based on the Dietary Reference Intakes (DRI), which are 10% to 35% protein, 20% to 35% fat, and 45% to 65% carbohydrate, for individuals who are at high risk for type 2 diabetes. Research is inconclusive regarding the effect of macronutrient distribution as a percentage of energy, independent of weight loss,  on outcomes in both adults with metabolic syndrome and individuals with prediabetes, related to the varying macronutrient distributions in study diets.

    Rating: Fair
    Imperative

    • Risks/Harms of Implementing This Recommendation

      None.

    • Conditions of Application

      None.

    • Potential Costs Associated with Application

      The costs of medical nutrition therapy (MNT).

    • Recommendation Narrative

      A total of 17 studies were included in the evidence analysis for this recommendation:

      • Nine positive quality randomized controlled trials (RCT) (Azadbakht et al, 2005; Lindstrom et al, 2006; McLaughlin et al, 2006; Camhi et al, 2010; Gulseth et al, 2010; Lee et al, 2009; Muzio et al, 2007; Paniagua et al, 2011; and Tierney et al, 2011)
      • Two neutral quality RCTs (Sarkkinen et al, 1996; Wolever and Mehling, 2003)
      • One positive quality cluster randomized trial (Zhang et al, 2011)
      • Three neutral quality randomized crossover trials (Melton et al, 2009; Khoury et al, 2010; Konig et al, 2012)
      • One neutral quality prospective cohort study (Feskens et al, 1995)
      • One positive quality non-randomized controlled trial (Kolovou et al, 2006).

      In Adults with Metabolic Syndrome

      • Glycemic-related outcomes (FBG, random BG, two-hour post-prandial BG, A1C):
        • Research is inconclusive on the effect of macronutrient distribution (as a percentage of energy), independent of weight loss,  on glycemic-related outcomes in adults with metabolic syndrome, related to the varying macronutrient distributions in study diets (12% to 30% protein; 20% to 38% fat; 48% to 65% carbohydrate)
        • However, two feeding studies, also with diets of varying macronutrient distributions report inconclusive results regarding the effect of macronutrient distribution on post-prandial glycemia and insulinemia
        • Additional longer-term intervention studies are needed to ascertain an effect of macronutrient distribution on glycemic-related outcomes in adults with metabolic syndrome with or without meeting the metabolic syndrome criteria for impaired glucose tolerance and impaired fasting glucose
        • Evidence is based on the following: Azadbakht et al, 2005; Khoury et al, 2010; Konig et al, 2012; Lee et al, 2009; Muzio et al, 2007; Paniagua et al, 2011; Tierney et al, 2011; Zhang et al, 2011.
      • Lipid outcomes (TG, HDL):
        • Research is inconclusive on the effect of macronutrient distribution (as a percentage of energy), independent of weight loss,  on lipid outcomes in adults with metabolic syndrome, related to the varying macronutrient distributions in study diets (12% to 30% protein; 20% to 38% fat; 48% to 65% carbohydrate)
        •  Additional longer-term intervention studies are needed to ascertain an effect of macronutrient distribution on lipid outcomes in adults with metabolic syndrome with or without meeting the metabolic syndrome criteria for lipid levels
        • Evidence is based on the following: Azadbakht et al, 2005; Camhi et al, 2010; Khoury et al, 2010; Kolovou et al, 2006; Lee et al, 2009; Muzio et al, 2007; Paniagua et al 2011; Tierney et al, 2011; Zhang et al, 2011.
      • Anthropometric outcomes (WC, WHR):
        • Research is inconclusive on the effect of macronutrient distribution (as a percentage of energy), independent of weight loss, on waist circumference (WC), independent of weight loss,  in adults with metabolic syndrome, related to the varying macronutrient distributions in study diets (12% to 30% protein; 20% to 38% fat; 48% to 65% carbohydrate)
        • Although not significant, there was a trend that macronutrient distribution may lead to a decrease in WC, when fat content was at least 30%. However, in one study with fat less than 30%, there was a positive effect on waist-to-hip ratio after one year
        • Additional longer-term intervention studies are needed to ascertain an effect of macronutrient distribution on anthropometric outcomes in adults with metabolic syndrome with or without meeting the metabolic syndrome criteria for anthropometric measures
        • Evidence is based on the following: Camhi et al, 2010; Lee et al, 2009; Muzio et al, 2007; Paniagua et al, 2011; Tierney et al, 2011; and Zhang et al, 2011.
      • Blood pressure outcomes:
        • Research is inconclusive on the effect of macronutrient distribution (as a percentage of energy), independent of weight loss,  on blood pressure in adults with metabolic syndrome, related to the varying macronutrient distributions in study diets (12% to 19% protein; 22% to 38% fat; 48% to 65% carbohydrate)
        • Additional longer-term intervention studies are needed to ascertain an effect of macronutrient distribution on blood pressure in adults with metabolic syndrome with or without meeting the metabolic syndrome criteria for blood pressure
        • Evidence is based on the following: Azadbakht et al, 2005; Gulseth et al, 2010; Muzio et al, 2007; Paniagua et al, 2011; Tierney et al, 2011; Zhang et al, 2011.
      • Renal outcomes:
        • There were no studies identified to evaluate the impact of macronutrient distribution (as a percentage of energy), independent of weight loss,  on renal outcomes in adults with metabolic syndrome
        • Intervention studies are needed to ascertain an effect of macronutrient distribution on renal outcomes in adults with metabolic syndrome with or without meeting the metabolic syndrome criteria for renal measures.

      In Individuals with Prediabetes

      • Glycemic-related outcomes (FBG, random BG, two-hour post-prandial BG, A1C):
        • Research is inconclusive on the effect of macronutrient distribution (as a percentage of energy), independent of weight loss,  on glycemic-related outcomes in individuals with prediabetes, related to the varying macronutrient distributions in study diets (15% protein; 25% to 45% fat; 40% to 60% carbohydrate)
        • Additional longer-term intervention studies are needed to quantify specific macronutrient intake ranges in individuals with prediabetes
        • Evidence is based on the following: Feskens et al, 1995; McLaughlin et al, 2006; Melton et al, 2009; Sarkkinen et al, 1996; Wolever and Mehling, 2003.
      • Lipid outcomes (TG, HDL):
        • Research is inconclusive on the effect of macronutrient distribution (as a percentage of energy), independent of weight loss,  on lipid outcomes in individuals with prediabetes, related to the varying macronutrient distributions in study diets (15% protein; 30% to 40% fat; 40% to 55% carbohydrate)
        • Additional longer-term intervention studies are needed to quantify specific macronutrient intake ranges in individuals with prediabetes
        • Evidence is based on the following: McLaughlin et al, 2006; Melton et al, 2009; Sarkkinen et al, 1996; Wolever and Mehling, 2003.
      • Anthropometric outcomes (WC, WHR):
        • Research is inconclusive on the effect of macronutrient distribution (as a percentage of energy), independent of weight loss,  on anthropometric outcomes in individuals with prediabetes, related to the varying macronutrient distributions in study diets (less than 30% of calories from fat)
        • Additional longer-term intervention studies are needed to ascertain an effect of macronutrient distribution on anthropometric outcomes in individuals with prediabetes
        • Evidence is based on the following: Lindstrom et al, 2006.
      • Blood Pressure outcomes:
        • Research is inconclusive on the effect of macronutrient distribution (as a percentage of energy), independent of weight loss,  on blood pressure in individuals with prediabetes, related to the varying macronutrient distributions in study diets (comparing 40% carbohydrate and 45% fat vs. 60% carbohydrate and 25% fat)
        • Additional longer-term intervention studies are needed to ascertain an effect of macronutrient distribution on blood pressure in individuals with prediabetes
        • Evidence is based on the following: McLaughlin et al, 2006.

    • Recommendation Strength Rationale

      For Adults with Metabolic Syndrome

      • Grade II evidence is available for the conclusion statements regarding the impact of macronutrient distribution, independent of weight loss, on adults with metabolic syndrome on:
        • Glycemic-related outcomes (such as fasting blood glucose, random blood glucose, two-hour post-prandial blood glucose, A1C)
        • Lipid outcomes (TG, HDL)
        • Anthropometric outcomes (WC, WHR)
        • Blood pressure.
      • Grade V (no evidence) is available to evaluate the impact of of macronutrient distribution, independent of weight loss on in adults with metabolic syndrome on renal outcomes.

      For Individuals with Prediabetes

      • Grade II evidence is available for the conclusion statements regarding the impact of macronutrient distribution, independent of weight loss, on the following outcomes:
        • Glycemic-related outcomes (such as fasting blood glucose, random blood glucose, two-hour post-prandial blood glucose, A1C)
        • Lipid (TG, HDL).
      • Grade III evidence is available for the conclusion statements regarding the impact macronutrient distribution, independent of weight loss, on the following outcomes:
        • Anthropometric measures (WC, WHR)
        • Blood pressure.

    • Minority Opinions

      Consensus reached.