Optimal nutrient distribution -
Disordered eating can make following an eating plan challenging Health care professionals should consider screening for disordered eating, refer to a mental health professional, and individualize nutrition therapy accordingly When sugar substitutes are used to reduce overall calorie and carbohydrate intake, people should be counseled to avoid compensating with intake of additional calories from other food sources.
SSB consumption in the general population contributes to a significantly increased risk of type 2 diabetes, weight gain, heart disease, kidney disease, nonalcoholic liver disease, and tooth decay The U. Food and Drug Administration FDA has reviewed several types of sugar substitutes for safety and approved them for consumption by the general public, including people with diabetes In this report, the term sugar substitutes refers to high-intensity sweeteners, artificial sweeteners, nonnutritive sweeteners, and low-calorie sweeteners.
These include saccharin, neotame, acesulfame-K, aspartame, sucralose, advantame, stevia, and luo han guo or monk fruit. Replacing added sugars with sugar substitutes could decrease daily intake of carbohydrates and calories.
These dietary changes could beneficially affect glycemic, weight, and cardiometabolic control. However, an American Heart Association science advisory on the consumption of beverages containing sugar substitutes that was supported by the ADA concluded there is not enough evidence to determine whether sugar substitute use definitively leads to long-term reduction in body weight or cardiometabolic risk factors, including glycemia Using sugar substitutes does not make an unhealthy choice healthy; rather, it makes such a choice less unhealthy.
If sugar substitutes are used to replace caloric sweeteners, without caloric compensation, they may be useful in reducing caloric and carbohydrate intake , although further research is needed to confirm these concepts Multiple mechanisms have been proposed for potential adverse effects of sugar substitutes, e.
As people aim to reduce their intake of SSBs, the use of other alternatives, with a focus on water, is encouraged Sugar alcohols represent a separate category of sweeteners. Like sugar substitutes, sugar alcohols have been approved by the FDA for consumption by the general public and people with diabetes.
Whereas sugar alcohols have fewer calories per gram than sugars, they are not as sweet. Therefore, a higher amount is required to match the degree of sweetness of sugars, generally bringing the calorie content to a level similar to that of sugars Use of sugar alcohols needs to be balanced with their potential to cause gastrointestinal effects in sensitive individuals.
Currently, there is little research on the potential benefits of sugar alcohols for people with diabetes It is recommended that adults with diabetes or prediabetes who drink alcohol do so in moderation one drink or less per day for adult women and two drinks or less per day for adult men.
Educating people with diabetes about the signs, symptoms, and self-management of delayed hypoglycemia after drinking alcohol, especially when using insulin or insulin secretagogues, is recommended.
The importance of glucose monitoring after drinking alcohol beverages to reduce hypoglycemia risk should be emphasized. It is important that health care providers counsel people with diabetes about alcohol consumption and encourage moderate and sensible use for people choosing to consume alcohol.
One alcohol-containing beverage is defined as oz beer, 5-oz wine, or 1. Starting with one drink per day, risk for reduced adherence to self-care and healthy lifestyle behaviors has been reported with increasing alcohol consumption Despite the potential glycemic and cardiovascular benefits of moderate alcohol consumption, alcohol intake may place people with diabetes at increased risk for delayed hypoglycemia , — This is particularly relevant for those using insulin or insulin secretagogues who can experience delayed nocturnal or fasting hypoglycemia after evening alcohol consumption.
Consuming alcohol with food can minimize the risk of nocturnal hypoglycemia , It is essential that people with diabetes receive education regarding the recognition and management of delayed hypoglycemia and the potential need for more frequent glucose monitoring after consuming alcohol , Comprehensive reviews and meta-analyses suggest a protective effect of moderate alcohol intake on the risk of developing type 2 diabetes, with a higher rate of diabetes in alcohol abstainers and heavy consumers , — Knott et al.
A meta-analysis and systematic review that examined the effects of specific types of alcohol beverage consumption and the incidence of type 2 diabetes found that wine consumption was associated with significantly lower diabetes risk, as compared with a smaller reduction in risk with beer and spirits.
While epidemiologic evidence shows a correlation between alcohol consumption and risk of diabetes, the evidence does not suggest that providers should advise abstainers to start consuming alcohol.
Without underlying deficiency, the benefits of multivitamins or mineral supplements on glycemia for people with diabetes or prediabetes have not been supported by evidence, and therefore routine use is not recommended. It is recommended that MNT for people taking metformin include an annual assessment of vitamin B12 status with guidance on supplementation options if deficiency is present.
The routine use of chromium or vitamin D micronutrient supplements or any herbal supplements, including cinnamon, curcumin, or aloe vera, for improving glycemia in people with diabetes is not supported by evidence and is therefore not recommended.
Scientific evidence does not support the use of dietary supplements in the form of vitamins or minerals to meet glycemic targets or improve CVD risk factors in people with diabetes or prediabetes, in the absence of an underlying deficiency — People with diabetes not achieving glucose targets may have an increased risk of micronutrient deficiencies , so maintaining a balanced intake of food sources that provide at least the recommended daily allowance for nutrients and micronutrients is essential For special populations, including women planning pregnancy, people with celiac disease, older adults, vegetarians, and people following an eating plan that restricts overall calories or one or more macronutrients, a multivitamin supplement may be justified A systematic review on the effect of chromium supplementation on glucose and lipid metabolism concluded that evidence is limited by poor study quality and heterogeneity in methodology and results , Evidence from clinical studies that evaluated magnesium , and vitamin D — supplementation to improve glycemia in people with diabetes is likewise conflicting.
However, evidence is emerging that suggests that magnesium status may be related to diabetes risk in people with prediabetes It is important to consider that nutritional supplements and herbal products are not standardized or regulated , Health care providers should ask about the use of supplements and herbal products, and providers and people with or at risk for diabetes should discuss the potential benefit of these products weighed against the cost and possible adverse effects and drug interactions.
The variability of herbal and micronutrient supplements makes research in this area challenging and makes it difficult to conclude effectiveness. To date, there is limited evidence supporting the addition of herbal supplements to manage glycemia.
Because of public interest and the lack of conclusive data, the National Center for Complementary and Integrative Health at the National Institutes of Health aims to answer important public health and scientific questions by funding and conducting research on complementary medicine.
Metformin is associated with vitamin B12 deficiency, with a recent systematic review recommending that annual blood testing of vitamin B12 levels be considered in metformin-treated people, especially in those with anemia or peripheral neuropathy This study found that even in the absence of anemia, B12 deficiency was prevalent.
The exact cause of B12 deficiency in people taking metformin is not known, but some research points to malabsorption caused by metformin, with other studies suggesting improvements in B12 status with calcium supplementation — The standard of treatment has been B12 injections, but new research suggest that high-dose oral supplementation may be as effective , More research is needed in this area.
All RDNs providing MNT in diabetes care should assess and monitor medication changes in relation to the nutrition care plan. For individuals with type 1 diabetes, intensive insulin therapy using the carbohydrate counting approach can result in improved glycemia and is recommended.
For adults using fixed daily insulin doses, consistent carbohydrate intake with respect to time and amount, while considering the insulin action time, can result in improved glycemia and reduce the risk for hypoglycemia.
A cautious approach to increasing mealtime insulin doses is suggested; continuous glucose monitoring CGM or self-monitoring of blood glucose SMBG should guide decision-making for administration of additional insulin.
RDNs providing MNT in diabetes care should assess and monitor medication changes in relation to the nutrition care plan. Along with other diabetes care providers, RDNs who possess advanced practice training and clinical expertise should take an active role in facilitating and maintaining organization-approved diabetes medication protocols.
For people with type 1 diabetes using basal-bolus insulin therapy, a primary focus for MNT should include guidance on adjusting insulin based on anticipated dietary intake, particularly carbohydrate intake 9 , — ; recent or expected physical activity; and glucose data.
Intensive insulin management education programs that include nutrition therapy have been shown to improve A1C 9 , , , — and quality of life 9 , For people using fixed daily insulin doses, carbohydrate intake on a day-to-day basis should be consistent with respect to time and amount per meal 9 , , Checking glucose 3 h after eating may help to determine if additional insulin adjustments i.
Because these insulin dosing algorithms require determination of anticipated nutrient intake to calculate the mealtime dose, health literacy and numeracy should be evaluated.
The effectiveness of insulin dosing decisions should be confirmed with a structured approach to SMBG or CGM to evaluate individual responses and guide insulin dose adjustments. In general, replacing saturated fat with unsaturated fats reduces both total cholesterol and LDL-C and also benefits CVD risk.
In type 2 diabetes, counseling people on eating patterns that replace foods high in carbohydrate with foods lower in carbohydrate and higher in fat may improve glycemia, triglycerides, and HDL-C; emphasizing foods higher in unsaturated fat instead of saturated fat may additionally improve LDL-C.
The recommendation for the general public to eat a serving of fish particularly fatty fish at least two times per week is also appropriate for people with diabetes.
Nutrition therapy that includes the development of an eating plan designed to optimize blood glucose trends, blood pressure, and lipid profiles is important in the management of diabetes and can lower the risk of CVD, CHD, and stroke 9.
Findings from clinical trials support the role of nutrition therapy for achieving glycemic targets and decreasing various markers of cardiovascular and hypertension risk 9 , 24 , — There has been increasing research examining the effects of high-fat, low-carbohydrate eating patterns on cardiometabolic risk factors, with two systematic reviews showing benefits of low-carbohydrate eating plans compared with low-fat eating plans on glycemic and CVD risk parameters in the treatment of type 2 diabetes see the section Low-Carbohydrate or Very Low-Carbohydrate Eating Patterns , The scientific rationale for decreasing saturated fat in the diet is based on the effect of saturated fat in raising LDL-C, a contributing factor in atherosclerosis In a Presidential Advisory on dietary fat and CVD, the American Heart Association concluded that lowering intake of saturated fat and replacing it with unsaturated fats, especially polyunsaturated fats, will lower the incidence of CVD Subgrouping of the studies suggested that benefit occurred by replacing saturated fat with polyunsaturated fat but not with carbohydrate or protein In a systematic review of observational studies, saturated fats were not associated with all-cause mortality, CVD, CHD, ischemic stroke, or type 2 diabetes, but limitations common to observational studies were noted The replacement of saturated fat with monounsaturated or polyunsaturated fat in food or replacement of trans fat with monounsaturated fat in food was inversely associated with CVD In general, replacing saturated fat with unsaturated fats, especially polyunsaturated fat, significantly reduces both total cholesterol and LDL-C, and replacement with monounsaturated fat from plant sources, such as olive oil and nuts, reduces CVD risk.
Replacing saturated fat with carbohydrate also reduces total cholesterol and LDL-C, but significantly increases triglycerides and reduces HDL-C , A recent meta-analysis of nine RCTs showed that, compared with control, the Mediterranean-style eating pattern, which is high in monounsaturated fats from plant sources such as olive oil and nuts, improved outcomes of glycemia, body weight, and cardiovascular risk factors in participants with type 2 diabetes A systematic review and meta-analysis of 24 studies and including 1, participants compared the effect of eating plans high in monounsaturated fat with that of eating plans high in carbohydrates.
The eating plans high in monounsaturated fat showed significant reductions in fasting glucose, triglycerides, body weight, and systolic blood pressure along with significant increases in HDL-C.
The systematic review and meta-analysis also reviewed four studies with a total of 44 participants comparing eating plans high in monounsaturated fat with those high in polyunsaturated fat.
The eating plans high in monounsaturated fat led to a significant reduction in fasting plasma glucose As is recommended for the general public, an increase in foods containing the long-chain omega-3 fatty acids EPA and docosahexaenoic acid DHA , such as are found in fatty fish, is recommended for individuals with diabetes because of their beneficial effects on lipoproteins, prevention of heart disease, and associations with positive health outcomes in observational studies , For people following a vegetarian or vegan eating pattern, omega-3 α-linoleic acid ALA found in plant foods such as flax, walnuts, and soy are reasonable replacements for foods high in saturated fat and may provide some CVD benefits, though the evidence is inconclusive.
Evidence does not conclusively support recommending omega-3 EPA and DHA supplements for all people with diabetes for the prevention or treatment of cardiovascular events.
Omega-3 fatty acid supplements have not reduced CVD events or mortality in randomized trials but may have utility in people who require triglyceride reduction , A meta-analysis of seven RCTs showed that increased trans fat intake did not result in changes in glucose, insulin, or triglyceride concentrations but led to an increase in total and LDL-C and a decrease in HDL-C concentrations Trans fats also have been associated with all-cause mortality, total CHD, and CHD mortality Some studies measuring urine sodium excretion in people with type 1 and type 2 diabetes have shown increased mortality associated with the lowest sodium intakes.
When individualizing sodium intake recommendations, careful consideration must be given to issues such as food preference, palatability, availability, and additional cost of fresh or specialty low-sodium products In individuals with diabetes and non—dialysis-dependent diabetic kidney disease DKD , reducing the amount of dietary protein below the recommended daily allowance 0.
Historically, low-protein eating plans were advised to reduce albuminuria and progression of chronic kidney disease in people with DKD, typically with improvements in albuminuria but no clear effect on estimated glomerular filtration rate. In addition, there is some indication that a low-protein eating plan may lead to malnutrition in individuals with DKD — The average daily level of protein intake for people with diabetes without kidney disease is typically 1—1.
Evidence does not suggest that people with DKD need to restrict protein intake to less than the average protein intake. For people with DKD and macroalbuminuria, changing to a more soy-based source of protein may improve CVD risk factors but does not appear to alter proteinuria , Correcting hyperglycemia is one strategy for the management of gastroparesis, as acute hyperglycemia delays gastric emptying.
Consultation by an RDN knowledgeable in the management of gastroparesis is helpful in setting and maintaining treatment goals Treatment goals include managing and reducing symptoms; correcting fluid, electrolyte, and nutritional deficiencies and glycemic imbalances; and addressing the precipitating cause s with appropriate drug therapy Correcting hyperglycemia is one strategy for the management of gastroparesis, as acute hyperglycemia delays gastric emptying , Modification of food and beverage intake is the primary management strategy, especially among individuals with mild symptoms.
People with gastroparesis may find it helpful to eat small, frequent meals. Replacing solid food with a greater proportion of liquid calories to meet individualized nutrition requirements may be helpful because consuming solid food in large volumes is associated with longer gastric emptying times , Large meals can also decrease the lower esophageal sphincter pressure, which may cause gastric reflux, providing further aggravation Many of the foods typically recommended for people with diabetes, such as leafy green salads, raw vegetables, beans, and fresh fruits, and other food like fatty or tough meat, can be some of the most difficult foods for the gastroparetic stomach to grind and empty , Notably, the majority of nutrition therapy interventions for gastroparesis are based on the knowledge of the pathophysiology and clinical judgment rather than empirical research The use of an insulin pump is another option for individuals with type 1 diabetes and insulin-requiring type 2 diabetes with gastroparesis A small but positive month trial reported a 1.
An insulin pump can be used to provide consistent basal insulin infusion, as well as the ability to modify mealtime insulin delivery doses as needed. The variable bolus feature allows the user to administer a portion of the meal bolus in an extended fashion over a longer period of time Use of this feature may help to decrease the risk of postprandial hyperglycemia as well as hypoglycemia.
When an individual with gastroparesis falls below target weight, nutrition support in the form of oral for acute exacerbation of symptoms , enteral, or parenteral nutrition should be considered Studies using personalized nutrition approaches to examine genetic, metabolomic, and microbiome variations have not yet identified specific factors that consistently improve outcomes in type 1 diabetes, type 2 diabetes, or prediabetes.
Currently, use of nutrition counseling approaches aimed at personalizing guidance based on genetic, metabolomic, and microbiome information is an area of intense research. Testing has become available commercially, with direct-to-consumer advertising. Some intriguing research has shown, for example, the wide interpersonal variability in blood glucose response to standardized meals that could be predicted by clinical and microbiome profiles At this point, however, no clear conclusions can be drawn regarding their utility owing to wide variations in the markers used for predicting outcomes, in the populations and nutrients studied, and in the associations found.
Ideally, an eating plan should be developed in collaboration with the person with prediabetes or diabetes and an RDN through participation in diabetes self-management education when the diagnosis of prediabetes or diabetes is made.
Regular follow-up with a diabetes health care provider is also critical to adjust other aspects of the treatment plan as indicated.
Unfortunately, national data indicate that most people with diabetes do not receive any nutrition therapy or formal diabetes education 4 , 9 , 16 , providing in-person or technology-enabled diabetes nutrition therapy and education integrated with medical management 9 , 12 , 13 , 15 , 16 , 19 , 22 , — , — ;.
engineering solutions that include two-way communication between the individual and his or her health care team to provide individualized feedback and tailored education based on the analyzed patient-generated health data 38 , , ;.
increasing the use of community health workers and peer coaches to provide culturally appropriate, ongoing support and clinically linked care coordination and improve the reach of MNT and DSMES 15 , 19 , 23 , 38 , , Evaluating nutrition evidence is complex given that multiple dietary factors influence glycemic management and CVD risk factors, and the influence of a combination of factors can be substantial.
Based on a review of the evidence, it is clear that knowledge gaps continue to exist and further research on nutrition and eating patterns is needed in individuals with type 1 diabetes, type 2 diabetes, and prediabetes. Future studies should address. the impact of different eating patterns compared with one another, controlling for supplementary advice such as stress reduction, physical activity, or smoking cessation ;.
the impact of weight loss on other outcomes which eating plans are beneficial only with weight loss, which can show benefit regardless of weight loss ;.
how cultural or personal preferences, psychological supports, co-occurring conditions, socioeconomic status, food insecurity, and other factors impact being consistent with an eating plan and its effectiveness;. the need for increased length and size of studies, to better understand long-term impacts on clinically relevant outcomes;.
comparisons of different delivery methods aided by technology e. ongoing cost-effectiveness studies that will further support coverage by third-party payers or bundling services into evolving value-based care and payment models.
The authors acknowledge Mindy Saraco Managing Director, Medical Affairs, ADA for her help with the development of the Consensus Report.
The authors acknowledge the invited peer reviewers who provided comments on an earlier draft of this report: Kelli Begay Indian Health Service, Rockville, MD , Guoxun Chen University of Tennessee, Knoxville, TN , Frank Hu Harvard T. Duality of Interest. The authors disclosed all potential financial conflicts of interest with industry.
These disclosures were discussed at the onset of the consensus statement development process. The ADA uses general revenues to fund development of its consensus reports and does not rely on industry support for these purposes. reports honorarium from the Academy of Nutrition and Dietetics and the ADA outside of the submitted work.
reports personal fees from Novo Nordisk, Merck, Amgen, Gilead, BOYDSense, the American Medical Group Association, and Janssen and grants from Sanofi, Pfizer, Merck, and Novo Nordisk outside of the submitted work.
reports personal fees from Sunstar Foundation outside of the submitted work. was previously employed by the ADA. reports grants from the National Institutes of Health and internal University of Michigan grants. reports a consulting relationship with dietdoctor.
com, which began after the Consensus Report was submitted to Diabetes Care. No other potential conflicts of interest relevant to this article were reported. Author Contributions. All authors were responsible for drafting the Consensus Report and revising it critically for important intellectual content.
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Data Sources, Searches, and Study Selection. EATING PATTERNS. MNT and Antihyperglycemic Medications Including Insulin. Article Information. Article Navigation. Continuing Evolution of Nutritional Therapy for Diabetes April 15 Nutrition Therapy for Adults With Diabetes or Prediabetes: A Consensus Report Alison B.
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toolbar search Search Dropdown Menu. toolbar search search input Search input auto suggest. Table 1 Goals of nutrition therapy.
View Large. Table 2 Academy of Nutrition and Dietetics evidence-based nutrition practice guidelines—recommended structure for the implementation of MNT for adults with diabetes 9. Initial series of MNT encounters : The RDN should implement three to six MNT encounters during the first 6 months following diagnosis and determine if additional MNT encounters are needed based on an individualized assessment.
MNT follow-up encounters: The RDN should implement a minimum of one annual MNT follow-up encounter. Table 3 Eating patterns reviewed for this report. Type of eating pattern. USDA Dietary Guidelines For Americans DGA 8 Emphasizes a variety of vegetables from all of the subgroups; fruits, especially whole fruits; grains, at least half of which are whole intact grains; lower-fat dairy; a variety of protein foods; and oils.
This eating pattern limits saturated fats and trans fats, added sugars, and sodium. Some plans include fruit e. Avoids starchy and sugary foods such as pasta, rice, potatoes, bread, and sweets. Often has a goal of 20—50 g of nonfiber carbohydrate per day to induce nutritional ketosis.
May also be reduced in sodium. Avoids grains, dairy, salt, refined fats, and sugar. Table 4 Quick reference conversion of percent calories from carbohydrate shown in grams per day as reported in the research reviewed for this report.
Replace sugar-sweetened beverages SSBs with water as often as possible. Selection of small-particle-size foods may improve symptoms of diabetes-related gastroparesis.
Strategies to improve access, clinical outcomes, and cost effectiveness include the following. reducing barriers to referrals and allowing self-referrals to MNT and DSMES; providing in-person or technology-enabled diabetes nutrition therapy and education integrated with medical management 9 , 12 , 13 , 15 , 16 , 19 , 22 , — , — ; engineering solutions that include two-way communication between the individual and his or her health care team to provide individualized feedback and tailored education based on the analyzed patient-generated health data 38 , , ; increasing the use of community health workers and peer coaches to provide culturally appropriate, ongoing support and clinically linked care coordination and improve the reach of MNT and DSMES 15 , 19 , 23 , 38 , , Diabetes self-management education and support in type 2 diabetes: a joint position statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics.
Search ADS. Management of hyperglycemia in type 2 diabetes, a patient-centered approach: update to a position statement of the American Diabetes Association and the European Association for the Study of Diabetes. American Diabetes Association.
Nutrition therapy recommendations for the management of adults with diabetes. Management of diabetes in pregnancy: Standards of Medical Care in Diabetes— Institute of Medicine. Accessed 2 October Department of Health and Human Service; U.
Accessed 18 January Academy of Nutrition and Dietetics Nutrition practice guideline for type 1 and type 2 diabetes in adults: systematic review of evidence for medical nutrition therapy effectiveness and recommendations for integration into the nutrition care process.
Nutrition Care Process and Model: ADA adopts road map to quality care and outcomes management. Legal Information Institute. Academy of Nutrition and Dietetics: Revised Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists Competent, Proficient, and Expert in Diabetes Care.
Diet or diet plus physical activity versus usual care in patients with newly diagnosed type 2 diabetes: the Early ACTID randomised controlled trial. The effect of medical nutrition therapy by a registered dietitian nutritionist in patients with prediabetes participating in a randomized controlled clinical research trial.
Imbedding interdisciplinary diabetes group visits into a community-based medical setting. Dietitian-coached management in combination with annual endocrinologist follow up improves global metabolic and cardiovascular health in diabetic participants after 24 months.
Briggs Early. Position of the Academy of Nutrition and Dietetics: the role of medical nutrition therapy and registered dietitian nutritionists in the prevention and treatment of prediabetes and type 2 diabetes.
A systematic review and meta-analysis of nutrition therapy compared with dietary advice in patients with type 2 diabetes. Does diabetes self-management education in conjunction with primary care improve glycemic control in Hispanic patients?
A systematic review and meta-analysis. Lynch EB, Liebman R, Ventrelle J, Avery EF, Richardson D. A self-management intervention for African Americans with comorbid diabetes and hypertension: a pilot randomized controlled trial. Prev Chronic Dis ; Diabetes self-management education for adults with type 2 diabetes mellitus: a systematic review of the effect on glycemic control.
Effects of the First Line Diabetes Care FiLDCare self-management education and support project on knowledge, attitudes, perceptions, self-management practices and glycaemic control: a quasi-experimental study conducted in the Northern Philippines.
The effectiveness and cost of lifestyle interventions including nutrition education for diabetes prevention: a systematic review and meta-analysis. Academy of Nutrition and Dietetics Evidence Analysis Library. MNT: cost effectiveness, cost-benefit, or economic savings of MNT [Internet].
Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. The Finnish Diabetes Prevention Study DPS : lifestyle intervention and 3-year results on diet and physical activity.
The long-term effect of lifestyle interventions to prevent diabetes in the China Da Qing Diabetes Prevention Study: a year follow-up study. Sustained reduction in the incidence of type 2 diabetes by lifestyle intervention: follow-up of the Finnish Diabetes Prevention Study.
Diabetes Prevention Program Research Group. Long-term effects of lifestyle intervention or metformin on diabetes development and microvascular complications over year follow-up: the Diabetes Prevention Program Outcomes Study.
Notably, no studies have demonstrated that addition of protein to carbohydrate to a pre-exercise feeding in these amounts may hinder exercise performance. Similarly, Rustad and colleagues [ 81 ] reported that adding protein 0.
To support recovery upon completion of exercise bouts that can deplete stored fuels and may cause significant damage to the muscle tissue, post-exercise nutrient timing strategies are of great interest. Ivy et al. These findings replicated previous findings [ 83 ] by this research group and led them to conclude that the addition of protein favorably promoted early phases of glycogen recovery.
Berardi et al. As more research has been completed on the topic, the potential benefits of adding protein have been questioned.
For example, Jentjens and colleagues [ 63 ] failed to show an improvement in muscle glycogen restoration with a combination of carbohydrate 1. Howarth and colleagues [ 86 ] later came to a similar conclusion regarding the addition of protein and extended these findings also to report that a higher dose of carbohydrate 1.
For example, Kraemer and colleagues [ 87 ] had participants ingest a combination of carbohydrate, protein, and fat or an isoenergetic maltodextrin placebo for seven days before two consecutive days of resistance exercise. Moreover, markers of muscle damage e.
A few years later, however, Fujita and colleagues [ 90 ] attempted to replicate their study findings and instead determined that MPS rates were similar between pre-exercise and post-exercise ingestion.
While many people use the Fujita paper to discount the pre-exercise period, it should be noted that significant increases in MPS rates occurred when nutrients were administered before and after the resistance training bout in comparison to a non-energetic control suggesting that nutrient delivery itself , as opposed to timing of delivery, should be a larger priority.
A later study by Bird et al. Using a crossover study design, participants also ingested a placebo that consisted of water flavored with a non-nutritive sweetener in similar volumes at the same times.
They reported that delivering nutrients versus none at all did significantly increase the volume of exercise completed and reduced concentrations of serum proteins indicative of muscle damage. Bird et al. While these findings are encouraging, the studies are limited by the dosage of EAA provided as other studies have indicated that higher EAA doses up to 12 g may maximally stimulate MPS.
As such, future research in this area should identify if different doses of EAA or combining a carbohydrate solution with varying doses of intact proteins consumed during resistance exercise bouts can further impact performance and resistance training adaptations.
In this respect, when sufficient protein is supplied, it may be that carbohydrate has no additional adaptive benefit.
As an example of this, Hulmi and colleagues [ 97 ] showed no benefit in resistance training adaptations when a combination of maltodextrin carbohydrate Changes in strength, hypertrophy, and body composition were assessed, and significant increases in lean body mass, 1RM strength, type II muscle fiber cross-sectional area, and higher muscle creatine and glycogen levels were found when the supplements were consumed immediately before and after workouts as opposed to consuming them in the morning and evening.
Furthermore, Cribb and Hayes also provided creatine while the other studies did not, which has been shown in multiple investigative scenarios to augment the muscular adaptations seen while resistance training [ 98 , 99 , ].
Specifically, insulin promotes anti-catabolic effects in muscle [ ], thereby shifting protein balance to favor anabolism. This would suggest that post-workout carbohydrate supplementation likely exerts minimal influence from a muscle development standpoint provided adequate protein is consumed.
However, when optimal carbohydrate is delivered the impact of adding protein irrespective of when it is provided appears to offer little to no additional benefit on endurance or resistance exercise performance as well as the recovery of reduced muscle glycogen.
Much like the work on glycogen recovery, studies involving resistance training and optimization of adaptations seen from resistance training also point towards a higher priority being given towards the total amount of protein consumed during the day.
Therefore, if total protein needs are met, the importance of adding carbohydrate and even more so in a timed fashion may be limited. A key point of discussion, however, lies with whether or not total energy needs are also being met, particularly in athletes undergoing large volumes of training and more so in those athletes that have high amounts of lean as well as body mass.
In these situations, it certainly remains possible that the addition of carbohydrate to a protein feeding may help the athlete achieve an appropriate energy intake, which certainly may go on to impact the extent to which adaptations occur.
In response to EAA ingestion and independent of leucine content, MPS rates and several signaling proteins related to muscle hypertrophy i.
were significantly increased. While more research certainly needs to be conducted to better identify the potential impact and role of protein intake before endurance exercise, the priority for an endurance athlete in the hours leading up to competition should be focused on appropriate carbohydrate intake to fully maximize endogenous production of glycogen.
As with endurance exercise, the majority of studies that have employed some form of protein or amino acid ingestion before bouts of resistance exercise have done so in conjunction with an identical dose during the post-exercise period as well.
For example, Tipton and colleagues [ ] used an acute resistance exercise and feeding model to report that MPS rates were similar when a g dose of whey protein was ingested immediately before or immediately after a bout of lower body resistance training.
Andersen et al. In this study, participants were randomized to ingest either 25 g of a protein blend In the group that consumed the protein-amino acid blend, type I and type II muscle fibers experienced a significant increase in size. Also, the protein-amino acid group experienced a significant increase in squat jump height while no changes occurred in the carbohydrate group.
Using a similar study design, Hoffman and colleagues [ ] had collegiate football players who had been regularly performing resistance-training ingest 42 g of hydrolyzed collagen protein either immediately before and immediately after exercise, or in the morning and evening over the course of ten weeks of resistance training.
In this study, the timing of protein intake did not impact changes in strength, power and body composition experienced from the resistance-training program.
When examining the discrepant findings, one must consider a few things. First, the protein source in the Hoffman et al. study was mostly a collagen hydrolysate i. Finally, the study participants in the Andersen et al.
More recently, Schoenfeld and colleagues [ ] published the first longitudinal study to directly compare the effects of ingesting 25 g of whey protein isolate either immediately before or immediately after each workout. This study is significant as it is the first investigation to attempt to compare pre versus post-workout ingestion of protein.
The authors raised the question that the size, composition, and timing of a pre-exercise meal may impact the extent to which adaptations are seen in these studies. However, a key limitation of this investigation is the very limited training volumes these subjects performed.
The total training sessions over the week treatment period was 30 sessions i. One would speculate that the individuals who would most likely benefit from peri-workout nutrition are those who train at much higher volumes. For instance, American collegiate athletes per NCAA regulations NCAA Bylaw 2.
Thus, the average college athlete trains more in two weeks than most subjects train during an entire treatment period in studies in this category. In one of the only studies to use older participants, Candow and colleagues [ 15 ] assigned 38 men between the ages of 59—76 years to ingest a 0.
While protein administration did favorably improve resistance-training adaptations, the timing of protein before or after workouts did not invoke any differential change. An important point to consider with the results of this study is the sub-optimal dose of protein approximately 26 g of whey protein versus the known anabolic resistance that has been demonstrated in the skeletal muscle of elderly individuals [ ].
In this respect, the anabolic stimulus from a g dose of whey protein may not have sufficiently stimulated muscle protein synthesis or have been of appropriate magnitude to induce differences between conditions.
Clearly, more research is needed to determine if a greater dose of protein delivered before or after a workout may exert an impact on adaptations seen during resistance training in an elderly population.
Limited studies are available that have examined the effect of providing protein throughout an acute bout of resistance exercise, particularly studies designed to explicitly determine if protein administration during exercise was more favorable than other times of administration.
However, when examined over the course of 12 weeks, the increases in fiber size seen after ingesting a solution containing 6 g of EAA alone was less than when it was combined with carbohydrate [ 96 ].
The post-exercise time period has been aggressively studied for its ability to heighten various training outcomes. While a large number of acute exercise and nutrient administration studies have provided multiple mechanistic explanations for why post-exercise feeding may be advantageous [ , , , , ], other studies suggest this study model may not be directly reflective of adaptations seen over the course of several weeks or months [ ].
As highlighted throughout the pre-exercise protein timing section, the majority of studies that have examined some aspect of post-exercise protein timing have done so while also administering an identical dose of protein immediately before each workout [ 16 , , , ].
These results, however, are not universal as Hoffman et al. Of note, participants in the Hoffman study were all highly-trained collegiate athletes who reported consuming a hypoenergetic diet.
Candow et al. As mentioned previously, it is possible that the dose of protein may not have been an appropriate amount to properly stimulate anabolism. In this respect, a small number of studies have examined the impact of solely ingesting protein after exercise.
As discussed earlier, Tipton and colleagues [ ] used an acute model to determine changes in MPS rates when a g bolus of whey protein was ingested immediately before or immediately after a single bout of lower-body resistance training. MPS rates were significantly, and similarly, increased under both conditions.
Until recently, the only study that examined the effects of post-exercise protein timing in a longitudinal manner was the work of Esmarck et al. In this study, 13 elderly men average age of 74 years consumed a small combination of carbohydrates 7 g , protein 10 g and fat 3 g either immediately within 30 min or 2 h after each bout of resistance exercise done three times per week for 12 weeks.
Changes in strength and muscle size were measured, and it was concluded that ingesting nutrients immediately after each workout led to greater improvements in strength and muscle cross-sectional area than when the same nutrients were ingested 2 h later.
While interesting, the inability of the group that delayed supplementation but still completed the resistance training program to experience any measurable increase in muscle cross-sectional area has led some to question the outcomes resulting from this study [ 5 , ].
Further and as discussed previously with the results of Candow et al. Schoenfeld and colleagues [ ] published results that directly examined the impact of ingesting 25 g of whey protein immediately before or immediately after bouts of resistance-training.
All study participants trained three times each week targeting all major muscle groups over a week period, and the authors concluded no differences in strength and hypertrophy were seen between the two protein ingestion groups.
These findings lend support to the hypothesis that ingestion of whey protein immediately before or immediately after workouts can promote improvements in strength and hypertrophy, but the time upon which nutrients are ingested does not necessarily trump other feeding strategies.
Reviews by Aragon and Schoenfeld [ ] and Schoenfeld et al. The authors suggested that when recommended levels of protein are consumed, the effect of timing appears to be, at best, minimal. Indeed, research shows that muscles remain sensitized to protein ingestion for at least 24 h following a resistance training bout [ ] leading the authors to suggest that the timing, size and composition of any feeding episode before a workout may exert some level of impact on the resulting adaptations.
In addition to these considerations, recent work by MacNaughton and colleagues [ ] reported that the acute ingestion of a g dose versus g of whey protein resulted in significantly greater increases in MPS in young subjects who completed an intense, high volume bout of resistance exercise that targeted all major muscle groups.
Notwithstanding these conclusions, the number of studies that have truly examined a timing question is rather scant. Moreover, recommendations must capture the needs of a wide range of individuals, and to this point, a very small number of studies have examined the impact of nutrient timing using highly trained athletes.
From a practical standpoint, some athletes may struggle, particularly those with high body masses, to consume enough protein to meet their required daily needs. As a starting point, it is important to highlight that most of the available research on this topic has largely used non-athletic, untrained populations except two recent publications using trained men and women [ , ].
Whether or not these findings apply to highly trained, athletic populations remains to be seen. Changes in weight loss and body composition were compared, and slightly greater weight loss occurred when the majority of calories was consumed in the morning.
As a caveat to what is seemingly greater weight loss when more calories are shifted to the morning meals, higher amounts of fat-free mass were lost as well, leading to questions surrounding the long-term efficacy of this strategy regarding weight management and metabolic activity.
Notably, this last point speaks to the importance of evenly spreading out calories across the day and avoiding extended periods of time where no food, protein in particular, is consumed.
A large observational study [ ] examined the food intake of free-living individuals males and females ,and a follow-up study from the same study cohort [ ] reported that the timing of food consumption earlier vs. later in the day was correlated to the total daily caloric intake.
Wu and colleagues [ ] reported that meals later in the day lead to increased rates of lipogenesis and adipose tissue accumulation in an animal model and, while limited, human research has also provided support. Previously it has been shown that people who skip breakfast display a delayed activation of lipolysis along with an increase in adipose tissue production [ , ].
More recently, Jakubowicz and colleagues [ ] had overweight and obese women consume cal each day for a week period. Approximately 2. While these results provide insight into how calories could be more optimally distributed throughout the day, a key perspective is that these studies were performed in sedentary populations without any form of exercise intervention.
Thus, their relevance to athletes or highly active populations might be limited. Furthermore, the current research approach has failed to explore the influence of more evenly distributed meal patterns throughout the day. Meal frequency is commonly defined as the number of feeding episodes that take place each day.
For years, recommendations have indicated that increasing meal frequency may serve as an effective way to influence weight loss, weight maintenance, and body composition.
These assertions were based upon the epidemiological work of Fabry and colleagues [ , ] who reported that mean skinfold thickness was inversely related to the frequency of meals. One of these studies involved overweight individuals between 60 and 64 years of age while the other investigation involved 80 participants between the ages of 30—50 years of age.
An even larger study published by Metzner and colleagues [ ] reported that in a sample of men and women between 35 and 60 years of age, meal frequency and adiposity were inversely related.
While intriguing, the observational nature of these studies does not agree with more controlled experiments. For example, a study by Farshchi et al.
The irregular meal pattern was found to result in increased levels of appetite, and hunger leading one to question if the energy provided in each meal was inadequate or if the energy content of each meal could have been better matched to limit these feelings while still promoting weight loss.
Furthermore, Cameron and investigators [ ] published what is one of the first studies to directly compare a greater meal frequency to a lower frequency. In this study, 16 obese men and women reduced their energy intake by kcals per day and were assigned to one of two isocaloric groups: one group was instructed to consume six meals per day three traditional meals and three snacks , while the other group was instructed to consume three meals per day for an eight-week period.
Changes in body mass, obesity indices, appetite, and ghrelin were measured at the end of the eight-week study, and no significant differences in any of the measured endpoints were found between conditions.
These results also align with more recent results by Alencar [ ] who compared the impact of consuming isocaloric diets consisting of two meals per day or six meals per day for 14 days in overweight women on weight loss, body composition, serum hormones ghrelin, insulin , and metabolic glucose markers.
No differences between groups in any of the measured outcomes were observed. A review by Kulovitz et al. Similar conclusions were drawn in a meta-analysis by Schoenfeld and colleagues [ ] that examined the impact of meal frequency on weight loss and body composition.
Although initial results suggested a potential advantage for higher meal frequencies on body composition, sub-analysis indicated that findings were confounded by a single study, casting doubt as to whether the strategy confers any beneficial effects.
From this, one might conclude that greater meal frequency may, indeed, favorably influence weight loss and body composition changes if used in combination with an exercise program for a short period of time. Certainly, more research is needed in this area, particularly studies that manipulate meal frequency in combination with an exercise program in non-athletic as well as athletic populations.
Finally, other endpoints related to meal frequency i. may be of interest to different populations, but they extend beyond the scope of this position stand. An extension of altering the patterns or frequency of when meals are consumed is to examine the pattern upon which protein feedings occur.
Moore and colleagues [ ] examined the differences in protein turnover and synthesis rates when participants ingested different patterns, in a randomized order, of an g total dose of protein over a h measurement period following a bout of lower body resistance exercise.
One of the protein feeding patterns required participants to consume two g doses of whey protein isolate approximately 6 h apart. Another condition required the consumption of four, g doses of whey protein isolate every 3 h. The final condition required the participants to consume eight, g doses of whey protein isolate every 90 min.
Rates of muscle protein turnover, synthesis, and breakdown were compared, and the authors concluded that protein turnover and synthesis rates were greatest when intermediate-sized g doses of whey protein isolate were consumed every 3 h.
One of the caveats of this investigation was the very low total dose of protein consumed. Eighty grams of protein over a h period would be grossly inadequate for athletes performing high volumes of training as well as those who are extremely heavy e.
A follow-up study one year later from the same research group determined myofibrillar protein synthesis rates after randomizing participants into three different protein ingestion patterns and examined how altering the pattern of protein administration affected protein synthesis rates after a bout of resistance exercise [ ].
Two key outcomes were identified. First, rates of myofibrillar protein synthesis rates increased in all three groups. Second, when four, g doses of whey protein isolate were consumed every 3 h over a h post-exercise period, significantly greater in comparison to the other two patterns of protein ingestion rates of myofibrillar protein synthesis occurred.
In combining the results of both studies, one can conclude that ingestion of intermediate protein doses 20 g consumed every 3 h creates more favorable changes in both whole-body as well as myofibrillar protein synthesis [ , ]. Although both studies employed short-term methodology and other patterns or doses have yet to be examined, the results thus far consistently suggest that the timing or pattern in which high-quality protein is ingested may favorably impact net protein balance as well as rates of myofibrillar protein synthesis.
An important caveat to these findings is that supplementation in most cases was provided in exclusion of other macronutrients over the duration of the study. Consumption of mixed meals delays gastric emptying and thus may result in different metabolic effects.
Moreover, the fact that whey is a fast-absorbing protein source [ ] further confounds the ability to generalize results to traditional mixed-meal diets, as the potential for oxidation is increased with larger dosages, particularly in the absence of other macronutrients.
Whether acute MPS responses translate to longitudinal changes in hypertrophy or fiber composition also remains to be determined [ ]. Protein pacing involves the consumption of 20—40 g servings of high-quality protein, from both whole food and protein supplementation, evenly spaced throughout the day, approximately every 3 h.
The first meal is consumed within 60 min of waking in the morning, and the last meal is eaten within 3 h of going to sleep at night. Arciero and colleagues [ , ] have most recently demonstrated increased muscular strength and power in exercise-trained physically fit men and women using protein pacing compared to ingestion of similar sized meals at similar times but different protein contents, both of which included the same multi-component exercise training during a week intervention.
In support of this theory one can point to the well characterized changes seen in peak MPS rates within 90 min after oral ingestion of protein [ ] and the return of MPS rates to baseline levels in approximately 90 min despite elevations in serum amino acid levels [ ].
Thus if efficacious protein feedings are placed too close together it remains possible that the ability of skeletal muscle anabolism to be fully activated might be limited. While no clear consensus exists as to the acceptance of this theory, conflicting findings exist between longitudinal studies that did provide protein feedings in close proximity to each other [ 16 , , ], making this an area that requires more investigation.
Finally, while the mechanistic implications of pulsed vs. bolus protein feedings and their effect on MPS rates may help ultimately guide application, the practical importance has yet to be demonstrated. Eating before sleep has long been controversial [ , , ].
However, methodological considerations in the original studies such as the population used, time of feeding, and size of the pre-sleep meal confounds any conclusions that can be drawn.
Recent work using protein-centric beverages consumed min before sleep and 2 h after the last meal dinner have identified pre-sleep protein consumption as advantageous to MPS, muscle recovery, and overall metabolism in both acute and long-term studies [ , ].
For example, data indicate that 30—40 g of casein protein ingested min prior to sleep [ ] or via nasogastric tubing [ ] increased overnight MPS in both young and old men, respectively.
Likewise, in an acute setting, 30 g of whey protein, 30 g of casein protein, and 33 g of carbohydrate consumption min pre-sleep resulted in elevated morning resting metabolic rate in fit young men compared to a non-caloric placebo [ ].
Of particular interest is that Madzima et al. This infers that casein protein consumed pre-sleep maintains overnight lipolysis and fat oxidation. This finding was verifiedwhen Kinsey et al. It was concluded that pre-sleep casein did not blunt overnight lipolysis or fat oxidation.
Similar to Madzima et al. Of note, it appears that previous exercise training completely ameliorates any rise in insulin when eating at night before sleep [ ] and the combination of pre-sleep protein and exercise has been shown to reduce blood pressure and arterial stiffness in young obese women with prehypertension and hypertension [ ].
To date, only two studies involving nighttime protein have been carried out for longer than four weeks. Snijders et al. The group receiving the protein-centric supplement each night before sleep had greater improvements in muscle mass and strength over the weeks. Of note, this study was non-nitrogen balanced and the protein group received approximately 1.
More recently, in a nitrogen-balanced design using young healthy men and women, Antonio et al. All subjects maintained their usual exercise program. The authors reported no differences in body composition or performance between the morning and evening casein supplementation groups.
A potential explanation for the lack of findings might stem from the already high intake of protein by the study participants before the study commenced. However, it is worth noting that although not statistically significant, the morning group added 0.
Thus, it appears that protein consumption in the evening before sleep represents another opportunity to consume protein and other nutrients. Certainly more research is needed to determine if timing per se, or the mere addition of total daily protein can affect body composition or recovery via nighttime feeding.
Nutrient timing is an area of research that continues to gather interest from researchers, coaches, and consumers. In reviewing the literature, two key considerations should be made. First, all findings surrounding nutrient timing require appropriate context because factors such as age, sex, fitness level, previous fueling status, dietary status, training volume, training intensity, program design, and time before the next training bout or competition can influence the extent to which timing may play a role in the adaptive response to exercise.
Second, nearly all research within this topic requires further investigation. The reader must keep in perspective that in its simplest form nutrient timing is a feeding strategy that in nearly all situations may be helpful towards the promotion of recovery and adaptations towards training.
This context is important because many nutrient timing studies demonstrate favorable changes that do not meet statistical thresholds of significance thereby leaving the reader to interpret the level of practical significance that exists from the findings.
It is noteworthy that differences in real-world athletic performances can be so small that even strategies that offer a modicum of benefit are still worth pursuing. In nearly all such situations, this approach results in an athlete receiving a combination of nutrients at specific times that may be helpful and has not yet shown to be harmful.
This perspective also has the added advantage of offering more flexibility to the fueling considerations a coach or athlete may employ. Using this approach, when both situations timed or non-timed ingestion of nutrients offer positive outcomes then our perspective is to advise an athlete to follow whatever strategy offers the most convenience or compliance if for no other reason than to deliver vital nutrients in amounts at a time that will support the physiological response to exercise.
Finally, it is advisable to remind the reader that due to the complexity, cost and invasiveness required to answer some of these fundamental questions, research studies often employ small numbers of study participants.
Also, for the most part studies have primarily evaluated men. This latter point is particularly important as researchers have documented that females oxidize more fat when compared to men, and also seem to utilize endogenous fuel sources to different degrees [ 28 , 29 , 30 ].
Furthermore, the size of potential effects tends to be small, and when small potential effects are combined with small numbers of study participants, the ability to determine statistical significance remains low. Nonetheless, this consideration remains relevant because it underscores the need for more research to better understand the possibility of the group and individual changes that can be expected when the timing of nutrients is manipulated.
In many situations, the efficacy of nutrient timing is inherently tied to the concept of optimal fueling. Thus, the importance of adequate energy, carbohydrate, and protein intake must be emphasized to ensure athletes are properly fueled for optimal performance as well as to maximize potential adaptations to exercise training.
High-intensity exercise particularly in hot and humid conditions demands aggressive carbohydrate and fluid replacement. Consumption of 1. The need for carbohydrate replacement increases in importance as training and competition extend beyond 70 min of activity and the need for carbohydrate during shorter durations is less established.
Adding protein 0. Moreover, the additional protein may minimize muscle damage, promote favorable hormone balance and accelerate recovery from intense exercise. For athletes completing high volumes i.
The use of a 20—g dose of a high-quality protein source that contains approximately 10—12 g of the EAA maximizes MPS rates that remain elevated for three to four hours following exercise. Protein consumption during the peri-workout period is a pragmatic and sensible strategy for athletes, particularly those who perform high volumes of exercise.
Not consuming protein post-workout e. The impact of delivering a dose of protein with or without carbohydrates during the peri-workout period over the course of several weeks may operate as a strategy to heighten adaptations to exercise.
Like carbohydrate, timing related considerations for protein appear to be of lower priority than the ingestion of optimal amounts of daily protein 1.
In the face of restricting caloric intake for weight loss, altering meal frequency has shown limited effects on body composition. However, more frequent meals may be more beneficial when accompanied by an exercise program. The impact of altering meal frequency in combination with an exercise program in non-athlete or athlete populations warrants further investigation.
It is established that altering meal frequency outside of an exercise program may help with controlling hunger, appetite and satiety. Nutrient timing strategies that involve changing the distribution of intermediate-sized protein doses 20—40 g or 0.
One must also consider that other factors such as the type of exercise stimulus, training status, and consumption of mixed macronutrient meals versus sole protein feedings can all impact how protein is metabolized across the day. When consumed within 30 min before sleep, 30—40 g of casein may increase MPS rates and improve strength and muscle hypertrophy.
In addition, protein ingestion prior to sleep may increase morning metabolic rate while exerting minimal influence over lipolysis rates. In addition, pre-sleep protein intake can operate as an effective way to meet daily protein needs while also providing a metabolic stimulus for muscle adaptation.
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May 26 , Selection of Optimal Feeding Formula. Written by. Israeli MedTech Company Wants To Stop Hospitals From Making You Sicker.
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The glycemic index GI provides an assessment of the quality of CHO-containing foods based on their ability to raise blood glucose BG To decrease the glycemic response to dietary intake, low-GI CHO foods are exchanged for high-GI CHO foods.
Detailed lists can be found in the International Tables of Glycemic Index and Glycemic Load Values Systematic reviews and meta-analyses of randomized trials and large individual randomized trials of interventions replacing high-GI foods with low-GI foods have shown clinically significant improvements in glycemic control over 2 weeks to 6 months in people with type 1 or type 2 diabetes 44— This dietary strategy has also been shown to improve postprandial glycemia and reduce high-sensitivity C-reactive protein hsCRP over 1 year in people with type 2 diabetes 48reduce the number of hypoglycemic events over 24 to 52 weeks in adults and children with type 1 diabetes 47 and improve total cholesterol TC over 2 to 24 weeks in people with and without diabetes Irrespective of the comparator, recent systematic reviews and meta-analyses have confirmed the beneficial effect of low-GI diets on glycemic control and blood lipids in people with diabetes 49— Other lines of evidence extend these benefits.
A systematic review and meta-analysis of prospective cohort studies inclusive of people with diabetes showed that high GI and high glycemic load GL diets are associated with increased incidence of cardiovascular disease CVDwhen comparing the highest with the lowest exposures of GI and GL in women more than men over 6 to 25 years Dietary fibre includes the edible components of plant material that are resistant to digestion by human enzymes nonstarch polysaccharides and lignin, as well as associated substances.
They include fibres from commonly consumed foods as well as accepted novel fibres that have been synthesized or derived from agricultural by-products Although these recommendations do not differentiate between insoluble and soluble fibres or viscous and nonviscous fibres within soluble fibre, the evidence supporting metabolic benefit is greatest for viscous soluble fibre from different plant sources e.
beta-glucan from oats and barley, mucilage from psyllium, glucomannan from konjac mannan, pectin from dietary pulses, eggplant, okra and temperate climate fruits apples, citrus fruits, berries, etc. The addition of viscous soluble fibre has been shown to slow gastric emptying and delay the absorption of glucose in the small intestine, thereby improving postprandial glycemic control 54, Systematic reviews, meta-analyses of randomized controlled trials and individual randomized controlled trials have shown that different sources of viscous soluble fibre result in improvements in glycemic control assessed as A1C or fasting blood glucose FBG 56—58 and blood lipids 59— A lipid-lowering advantage is supported by Health Canada-approved cholesterol-lowering health claims for the viscous soluble fibres from oats, barley and psyllium 62— Despite contributing to stool bulking 65insoluble fibre has failed to show similar metabolic advantages in randomized controlled trials in people with diabetes 56,66, These differences between soluble and insoluble fibre are reflected in the EURODIAB prospective complications study, which demonstrated a protective association of soluble fibre that was stronger than that for insoluble fibre in relation to nonfatal CVD, cardiovascular CV mortality and all-cause mortality in people with type 1 diabetes However, this difference in the metabolic effects between soluble and insoluble fibre is not a consistent finding.
A recent systematic review and meta-analysis of prospective cohort studies in people with and without diabetes did not show a difference in risk reduction between fibre types insoluble, soluble or fibre source cereal, fruit, vegetable Given this inconsistency, mixed sources of fibre may be the ideal strategy.
Added sugars, especially from fructose-containing sugars high fructose corn syrup [HFCS], sucrose and fructosehave become a focus of intense public health concern. Fructose-containing sugars either in isocaloric substitution for starch or under ad libitum conditions have not demonstrated an adverse effect on lipoproteins LDL-C, TC, high-density lipoprotein cholesterol [HDL-C]body weight or markers of glycemic control A1C, FBG or fasting blood insulin 71— Similar results have been seen for added fructose.
Consumption of added fructose alone, in place of equal amounts of other sources of CHO mainly starchdoes not have adverse effects on body weight 74,75BP 76fasting TG 77,78postprandial TG 79markers of fatty liver 80 or uric acid 75, In fact, it may even lower A1C 75,82,83 in most people with diabetes.
Although HFCS has not been formally tested in controlled trials involving people with diabetes, there is no reason to expect that it would give different results than sucrose. Randomized controlled trials of head-to-head comparisons of HFCS vs. sucrose at doses from the 5th to 95th percentile of United States population intake have shown no differences between HFCS and sucrose over a wide range of cardiometabolic outcomes in participants with overweight or obesity without diabetes 84— Food sources of sugars may be a more important consideration than the type of sugar per se.
A wide range of studies including people with and without diabetes have shown an adverse association of sugar-sweetened beverages SSBs with risk of hypertension and coronary heart disease when comparing the highest with the lowest levels of intake 88, This adverse relationship may be specific to SSBs as the same adverse relationship has not been shown for total sugars, sucrose, or fructose 90—97fructose-containing sugars from fruit 79,98 or food sources of added sugars, such as whole grains and dairy products yogurt 98— The DRIs do not specify an AI or RDA for total fat, monounsaturated fatty acids MUFAsaturated fatty acids SFAor dietary cholesterol.
The quality of fat type of fatty acids has been shown to be a more important consideration than the quantity of fat for CV risk reduction.
Dietary strategies have tended to focus on the reduction of saturated fatty acids SFA and dietary cholesterol. These diets have shown improvements in lipids and other CV risk factors compared with higher SFA and cholesterol control diets More recent analyses have assessed the relation of different fatty acids with CV outcomes.
A systematic review and meta-analysis of prospective cohort studies inclusive of people with diabetes showed that diets low in trans fatty acids TFA are associated with less coronary heart disease CHD Another systematic review and meta-analysis of randomized controlled clinical outcome trials involving people with and without diabetes showed that diets low in SFA decrease combined CV events Pooled analyses of prospective cohort studies and large individual cohort studies also suggest that replacement of saturated fatty acids with high quality sources of monounsaturated fatty acids MUFA from olive oil, canola oil, avocado, nuts and seeds, and high quality sources of carbohydrates from whole grains and low GI index carbohydrate foods is associated with decreased incidence of CHDThe food source of the saturated fatty acids being replaced, however, is another important consideration.
Whereas adverse associations have been reliably established for meat as a food source of saturated fatty acids, the same has not been shown for some other food sources of saturated fatty acids e. such as dairy products and plant fats from palm and coconut A comprehensive review of long-chain omega-3 fatty acids LC-PUFAs eicosapentaenoic acid EPA and docosahexaenoic acid DHA from fish oils did not show an effect on glycemic control Large randomized clinical outcome trials of supplementation with omega-3 LC-PUFAs do not support their use in people with diabetes — The Outcome Reduction with Initial Glargine lntervention ORIGIN trial failed to show a CV or mortality benefit of supplementation with omega-3 LC-PUFA in 12, people with prediabetes or type 2 diabetes Subsequent systematic reviews and meta-analyses of randomized trials involving more than 75, participants with and without diabetes have failed to show a CV benefit of supplementation with long chain omega-3 PUFAs The Study of Cardiovascular Events in Diabetes ASCEND in 15, people with diabetes free of CV disease clinicaltrials.
gov registration number NCT will provide more data on the outcomes of supplementation with omega-3 LC-PUFA in people with diabetes. Although supplementation with omega-3 LC-PUFA has not been shown to be beneficial, consumption of fish may be.
The DRIs specify a recommended dietary allowance RDA for protein of 0. There is no evidence that the usual protein intake for most individuals 1 to 1. However, this intake in grams per kg per day should be maintained or increased with energy-reduced diets.
Protein quality has been shown to be another important consideration. A systematic review and meta-analysis of randomized controlled trials showed that replacement of animal protein with sources of plant protein improved A1C, FPG and fasting insulin in people with type 1 and type 2 diabetes over a median follow up of 8 weeks People with diabetes who have CKD should target a level of intake that does not exceed the RDA of 0.
When using a low-protein diet, harm due to malnutrition should not be ignored Both the quantity and quality high biological value of protein intake must be optimized to meet requirements for essential amino acids, necessitating adequate clinical and laboratory monitoring of nutritional status in the individual with diabetes and CKD.
Greater incorporation of plant sources of protein may also require closer monitoring of potassium as CKD progresses. The ideal macronutrient distribution for the management of diabetes can be individualized. Based on evidence for chronic disease prevention and adequacy of essential nutrients, the DRIs recommend acceptable macronutrient distribution ranges AMDRs for macronutrients as a percentage of total energy.
There may be a benefit of substituting fat as MUFA for carbohydrate Similarly, the replacement of refined high-GI CHO with MUFA
: Optimal nutrient distribution| Background | Reprints and permissions. The foods you eat can impact your fat loss efforts. The authors acknowledge the invited peer reviewers who provided comments on an earlier draft of this report: Kelli Begay Indian Health Service, Rockville, MD , Guoxun Chen University of Tennessee, Knoxville, TN , Frank Hu Harvard T. Read Free Online. Bird SP, Tarpenning KM, Marino FE. Comparison of a high-carbohydrate and a high-monounsaturated fat, olive oil-rich diet on the susceptibility of LDL to oxidative modification in subjects with type 2 diabetes mellitus. |
| Nutrient Recommendations and Databases | Britto, D. By Kris Gunnars, BSc. AgroFood Industry Hi-Tech. Soya products and serum lipids: A meta-analysis of randomised controlled trials. PubMed Google Scholar Mclellan TM, Pasiakos SM, Lieberman HR. Effects of high and lowfat dairy food on cardiometabolic risk factors: A meta-analysis of randomized studies. Sabate J, Oda K, Ros E. |
| Data Sources, Searches, and Study Selection | This context is important because many nutrient timing studies demonstrate favorable changes that do not meet statistical thresholds of significance thereby leaving the reader to interpret the level of practical significance that exists from the findings. Vitamin D supplementation in patients with diabetes mellitus type 2 on different therapeutic regimens: a one-year prospective study. Pooled analyses of prospective cohort studies and large individual cohort studies also suggest that replacement of saturated fatty acids with high quality sources of monounsaturated fatty acids MUFA from olive oil, canola oil, avocado, nuts and seeds, and high quality sources of carbohydrates from whole grains and low GI index carbohydrate foods is associated with decreased incidence of CHD , The number of encounters the person with diabetes might have with the RDN is described in Table 2 9. Howarth KR, Moreau NA, Phillips SM, Gibala MJ. DAFNE Study Group. Beulens JW, de Bruijne LM, Stolk RP, et al. |
| Dietary Reference Intakes | Search Dropdown Menu. header search search input Search input auto suggest. filter your search All Content All Journals Diabetes Care. Advanced Search. User Tools Dropdown. Sign In. Skip Nav Destination Close navigation menu Article navigation. Volume 42, Issue 5. Previous Article Next Article. Data Sources, Searches, and Study Selection. EATING PATTERNS. MNT and Antihyperglycemic Medications Including Insulin. Article Information. Article Navigation. Continuing Evolution of Nutritional Therapy for Diabetes April 15 Nutrition Therapy for Adults With Diabetes or Prediabetes: A Consensus Report Alison B. Evert ; Alison B. This Site. Google Scholar. Michelle Dennison ; Michelle Dennison. Christopher D. Gardner ; Christopher D. Timothy Garvey ; W. Timothy Garvey. Ka Hei Karen Lau ; Ka Hei Karen Lau. Janice MacLeod ; Janice MacLeod. Joanna Mitri ; Joanna Mitri. Raquel F. Pereira ; Raquel F. Kelly Rawlings ; Kelly Rawlings. Shamera Robinson ; Shamera Robinson. Laura Saslow ; Laura Saslow. Sacha Uelmen ; Sacha Uelmen. Patricia B. Urbanski ; Patricia B. William S. Yancy, Jr. Corresponding author: William S. Yancy Jr. yancy duke. Diabetes Care ;42 5 — Get Permissions. toolbar search Search Dropdown Menu. toolbar search search input Search input auto suggest. Table 1 Goals of nutrition therapy. View Large. Table 2 Academy of Nutrition and Dietetics evidence-based nutrition practice guidelines—recommended structure for the implementation of MNT for adults with diabetes 9. Initial series of MNT encounters : The RDN should implement three to six MNT encounters during the first 6 months following diagnosis and determine if additional MNT encounters are needed based on an individualized assessment. MNT follow-up encounters: The RDN should implement a minimum of one annual MNT follow-up encounter. Table 3 Eating patterns reviewed for this report. Type of eating pattern. USDA Dietary Guidelines For Americans DGA 8 Emphasizes a variety of vegetables from all of the subgroups; fruits, especially whole fruits; grains, at least half of which are whole intact grains; lower-fat dairy; a variety of protein foods; and oils. This eating pattern limits saturated fats and trans fats, added sugars, and sodium. Some plans include fruit e. Avoids starchy and sugary foods such as pasta, rice, potatoes, bread, and sweets. Often has a goal of 20—50 g of nonfiber carbohydrate per day to induce nutritional ketosis. May also be reduced in sodium. Avoids grains, dairy, salt, refined fats, and sugar. Table 4 Quick reference conversion of percent calories from carbohydrate shown in grams per day as reported in the research reviewed for this report. Replace sugar-sweetened beverages SSBs with water as often as possible. Selection of small-particle-size foods may improve symptoms of diabetes-related gastroparesis. Strategies to improve access, clinical outcomes, and cost effectiveness include the following. reducing barriers to referrals and allowing self-referrals to MNT and DSMES; providing in-person or technology-enabled diabetes nutrition therapy and education integrated with medical management 9 , 12 , 13 , 15 , 16 , 19 , 22 , — , — ; engineering solutions that include two-way communication between the individual and his or her health care team to provide individualized feedback and tailored education based on the analyzed patient-generated health data 38 , , ; increasing the use of community health workers and peer coaches to provide culturally appropriate, ongoing support and clinically linked care coordination and improve the reach of MNT and DSMES 15 , 19 , 23 , 38 , , Diabetes self-management education and support in type 2 diabetes: a joint position statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics. 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Academy of Nutrition and Dietetics: Revised Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists Competent, Proficient, and Expert in Diabetes Care. Diet or diet plus physical activity versus usual care in patients with newly diagnosed type 2 diabetes: the Early ACTID randomised controlled trial. The effect of medical nutrition therapy by a registered dietitian nutritionist in patients with prediabetes participating in a randomized controlled clinical research trial. Imbedding interdisciplinary diabetes group visits into a community-based medical setting. Dietitian-coached management in combination with annual endocrinologist follow up improves global metabolic and cardiovascular health in diabetic participants after 24 months. Briggs Early. Position of the Academy of Nutrition and Dietetics: the role of medical nutrition therapy and registered dietitian nutritionists in the prevention and treatment of prediabetes and type 2 diabetes. A systematic review and meta-analysis of nutrition therapy compared with dietary advice in patients with type 2 diabetes. Does diabetes self-management education in conjunction with primary care improve glycemic control in Hispanic patients? A systematic review and meta-analysis. Lynch EB, Liebman R, Ventrelle J, Avery EF, Richardson D. A self-management intervention for African Americans with comorbid diabetes and hypertension: a pilot randomized controlled trial. Prev Chronic Dis ; Diabetes self-management education for adults with type 2 diabetes mellitus: a systematic review of the effect on glycemic control. Effects of the First Line Diabetes Care FiLDCare self-management education and support project on knowledge, attitudes, perceptions, self-management practices and glycaemic control: a quasi-experimental study conducted in the Northern Philippines. 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Cardiovascular mortality, all-cause mortality, and diabetes incidence after lifestyle intervention for people with impaired glucose tolerance in the Da Qing Diabetes Prevention Study: a year follow-up study. Medical nutrition therapy and weight loss questions for the Evidence Analysis Library prevention of type 2 diabetes project: systematic reviews. Prevention of Type 2 Diabetes PDM Guideline [Internet]. Accessed 20 November Combined diet and physical activity promotion programs to prevent type 2 diabetes among persons at increased risk: a systematic review for the Community Preventive Services Task Force. A mobile phone-based health coaching intervention for weight loss and blood pressure reduction in a national payer population: a retrospective study. Long-term outcomes of a Web-based diabetes prevention program: 2-year results of a single-arm longitudinal study. The effect of technology-mediated diabetes prevention interventions on weight: a meta-analysis. Clinical and economic impact of a digital, remotely-delivered intensive behavioral counseling program on Medicare beneficiaries at risk for diabetes and cardiovascular disease. Virtual small groups for weight management: an innovative delivery mechanism for evidence-based lifestyle interventions among obese men. Translating the Diabetes Prevention Program into an online social network: validation against CDC standards. Weight loss efficacy of a novel mobile Diabetes Prevention Program delivery platform with human coaching. Diabetes prevention and weight loss with a fully automated behavioral intervention by email, web, and mobile phone: a randomized controlled trial among persons with prediabetes. Macronutrients, food groups, and eating patterns in the management of diabetes: a systematic review of the literature, Association of diet with glycated hemoglobin during intensive treatment of type 1 diabetes in the Diabetes Control and Complications Trial. 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Dietary fiber for the treatment of type 2 diabetes mellitus: a meta-analysis. Position of the Academy of Nutrition and Dietetics: health implications of dietary fiber. Glycemic index, postprandial glycemia, and the shape of the curve in healthy subjects: analysis of a database of more than 1, foods. Effect of a chicken-based diet on renal function and lipid profile in patients with type 2 diabetes: a randomized crossover trial. The effect of a high-egg diet on cardiovascular risk factors in people with type 2 diabetes: the Diabetes and Egg DIABEGG study—a 3-mo randomized controlled trial. Dietary tartary buckwheat intake attenuates insulin resistance and improves lipid profiles in patients with type 2 diabetes: a randomized controlled trial. Salba-chia Salvia hispanica L. in the treatment of overweight and obese patients with type 2 diabetes: a double-blind randomized controlled trial. 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In type 2 diabetes, randomisation to advice to follow a low-carbohydrate diet transiently improves glycaemic control compared with advice to follow a low-fat diet producing a similar weight loss. A high-protein low-fat diet is more effective in improving blood pressure and triglycerides in calorie-restricted obese individuals with newly diagnosed type 2 diabetes. Influence of fat and carbohydrate proportions on the metabolic profile in patients with type 2 diabetes: a meta-analysis. Long-term use of a high-complex-carbohydrate, high-fiber, low-fat diet and exercise in the treatment of NIDDM patients. Comparison of coronary risk factors and quality of life in coronary artery disease patients with versus without diabetes mellitus. Effect of dietary carbohydrate restriction on glycemic control in adults with diabetes: a systematic review and meta-analysis. van Zuuren. 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Relationship between intervention dose and outcomes in living well with diabetes—a randomized trial of a telephone-delivered lifestyle-based weight loss intervention. Telehealth delivery of the Diabetes Prevention Program to rural communities. While this data represents current scientific knowledge on nutrient needs, individual requirements may be higher or lower than the DRI recommendations. Recommended intakes of nutrients vary by age and sex and are known as Recommended Dietary Allowances RDAs and Adequate Intakes AIs. However, one value for each nutrient, known as the Daily Value DV , is selected for the labels of dietary supplements and foods. A DV is often, but not always, similar to one's RDA or AI for that nutrient. DVs were developed by the U. Food and Drug Administration FDA to help consumers determine the level of various nutrients in a standard serving of food in relation to their approximate requirement for it. The U. Department of Agriculture FoodData Central provides detailed information on the nutrient content of foods consumed in the U. Therefore, the primary purpose of this updated position stand is to refine recommendations made related to the timed consumption of carbohydrates and protein and how this can potentially affect the adaptive response to exercise. To expand upon the previous version, the current position stand now discusses research and recommendations related to meal patterns, timing, and distribution of protein, meal frequency and nighttime eating. It is the contention of the ISSN that these topics also fall under the purview of nutrient timing. Additionally, non-athletic or specialized clinical populations may also derive benefit from these strategies. Throughout each section, an attempt has been made to first highlight outcomes from acute studies before discussing those derived from training studies spanning several weeks or more. Moderate to high intensity e. It is well documented that glycogen stores are limited [ 18 , 19 ] and operate as a predominant source of fuel for up to a few hours during moderate to high-intensity aerobic exercise e. Importantly, as glycogen levels decline, the ability of an athlete to maintain exercise intensity and work output also decreases [ 19 ] while rates of tissue breakdown increase [ 23 , 24 ]. The simplest guideline to maximize endogenous glycogen stores is for a high-performance athlete to ingest appropriate amounts of carbohydrate relative to their intensity and volume of training. In the absence of considerable muscle damage, this carbohydrate intake level has been shown to maximize glycogen storage. It should be noted that most of the recommendations for carbohydrate intake are based on the needs of endurance athletes, and in particular, male endurance athletes. Moreover, studies have indicated that trained female athletes do not oxidize fat and carbohydrate at the same rates as males and may deplete endogenous glycogen stores to different degrees [ 28 , 29 , 30 , 31 ]. Perhaps those involved in strength-power sports need a lower intake of carbohydrate and instead should focus more on prioritizing their carbohydrate intake in the days leading up to competition, but more research is required as this topic has been critically evaluated in a review by Escobar et al. It should be noted that athletes often fail to meet recommended amounts of energy and carbohydrate; consequently [ 33 ], strategies to replenish carbohydrate stores may take priority toprepare for maximal performance in the next competition. Sherman and colleagues [ 2 , 34 ] also demonstrated success at maximizing intramuscular glycogen stores using similar approaches. Alternatively, Bussau et al. A similar approach by Fairchild et al. Overall, the ability of carbohydrate loading strategies to rapidly increase and maximize muscle glycogen levels is currently unquestioned, and many athletes and coaches are encouraged to consider making use of such a dietary regimen in the days leading up to a competitive event, particularly if their activity will significantly deplete endogenous skeletal muscle glycogen. The hours leading up to competition are often a highly prioritized period of feeding and studies have indicated that strategic fuel consumption can help to maximize muscle and liver glycogen levels. Carbohydrate feedings during this time increase endogenous glycogen stores while also helping to maintain blood glucose levels. Notably, Coyle et al. In addition to increasing stored glycogen, other studies have reported significant improvements in aerobic exercise performance [ 37 , 38 , 39 ]. However, not all studies have demonstrated a performance-enhancing effect. Additionally, and as a measure of practical importance, the need to ingest a pre-exercise meal or snacks high in carbohydrate goes up when the athlete has consumed relatively small amounts of carbohydrate in the days leading up to a competition or has not allowed for appropriate amounts of rest and recovery [ 20 , 24 ]. In this respect, another priority becomes maintaining a favorable balance with the digestive system and avoiding the consumption of too much food or fluid before competition. Practically speaking, many endurance events begin in the early morning hours and finding an adequate balance between rest and fuel must be considered. In this respect, two studies have reported that solid or liquid forms of carbohydrates similarly promote glycogen resynthesis allowing athletes more flexibility when selecting food sources [ 40 , 41 ]. A certain degree of dogma still clouds the recommendation to ingest certain types of carbohydrate, or avoid carbohydrate altogether, in the final few hours before an event. From these findings, it has been surmised that excessive carbohydrate consumption, and in particular fructose consumption, in the initial hours before exercise may negatively impact exercise performance perhaps due to rebound hypoglycemia. Indeed, given the rise in insulin due to carbohydrate ingestion coupled with up-regulation of GLUT-4 transporters from the initiated exercise stimulus, there may be a decrease, rather than increase, in blood glucose at the onset of activity that could negatively impact performance. However, while a number of athletes may be affected by this phenomenon, a study by Moseley et al. A review by Hawley and Burke summarized the results of several studies that provided some form of carbohydrate at least 60 min before exercise. They found no adverse impact on performance. Moreover, Galloway and colleagues [ 45 ] used a double-blind, placebo-controlled approach to compare performance outcomes related to ingestion of a placebo or a 6. Ingesting carbohydrate 30 min before exercise led to greater increases in exercise capacity. They concluded that performance was similar for both types of carbohydrate. The delivery of carbohydrate remains a priority once a workout or competition commences. Several studies have indicated that the pattern or timing of carbohydrate feedings surrounding endurance exercise may be important. For example, Fielding and colleagues [ 50 ] required cyclists to ingest the same dose of carbohydrate every 30 min or every 60 min over the course of a four-hour exercise bout. When carbohydrate was ingested more frequently, performance was improved. Two contrasting papers that operate as extensions of this work include work by Schweitzer et al. It is important to realize that key differences such as the duration of the exercise bout, the nature of the performance assessment fixed distance vs. time-to-exhaustion and amount of carbohydrate that was delivered all differed between these studies and can help to explain the differences in outcomes being reported. A classic paper by Widrick et al. Increased power outputs were recorded when exercise began with high muscle glycogen levels, and even greater power was achieved when carbohydrate was frequently provided throughout the exercise protocol. The four feeding conditions were: a placebo beverage 30 min before and a 6. As with the findings of Widrick et al. Collectively, these findings somewhat prioritize carbohydrate feeding during the exercise session and could lead some to argue that if pre-exercise carbohydrate feeding strategies are neglected, then delivering appropriate carbohydrate throughout an exercise bout may help offset the potential for performance decrement. However, one must cautiously explore this approach as to avoid overwhelming the gastrointestinal system potentially leading to cramping and discomfort once exercise begins. In this respect one should consider the findings of Newell et al. Importantly, no differences in performance were found between these two feeding strategies suggesting that for those athletes who may not be able to tolerate higher doses of carbohydrates, a moderate regimen of carbohydrate feeding throughout a prolonged bout of exercise can still promote similar improvements in performance. Other important considerations related to the potential ergogenic impact of carbohydrates have been critically highlighted in recent reviews by Colombani et al. In both papers, the authors contend that the ability of carbohydrate administration during bouts of exercise spanning less than 70 min to operate in an ergogenic fashion is largely mixed in the literature. Whether or not these results translate to intermittent sports remains to be thoroughly investigated. A review by Phillips and colleagues [ 58 ] supports the notion that carbohydrate administration throughout intermittent, team-sport activities improves certain types of performance as well as general indicators of mental drive and acuity, but evidence regarding benefits of acute deviations in timing is still lacking. No performance or capacity measurements were made, but the authors did report that either feeding pattern was able to maintain glucose, insulin, glycerol, non-esterified fatty acid, and epinephrine levels. More recently, Mizuno and colleagues [ 60 ] concluded that timing the intake of a carbohydrate gel 1. The recovery of lost muscle glycogen operates as a key nutritional goal, and post-exercise ingestion of carbohydrate continues to be a popular and efficient nutrient timing strategy to maximize replenishment of lost muscle glycogen. Subsequent work has since refined conclusions surrounding this topic, namely that the timing of post-exercise carbohydrate administration holds the highest level of importance under two primary situations: 1 when rapid restoration of muscle glycogen is a primary goal and 2 when inadequate amounts of carbohydrate are being delivered. In light of these considerations, muscle glycogen levels can be rapidly and maximally restored using an aggressive post-exercise feeding regimen of carbohydrates. Ingesting 0. Similarly, favorable outcomes have also been shown when 1. Outside of situations where rapid recovery is truly needed, and daily carbohydrate intake is matching energy demands, the importance of timed carbohydrate ingestion is notably decreased. However, in no situation has timed carbohydrate ingestion been shown to negatively impact performance or recovery. If an athlete participating in heavy exercise is not able, or even not sure if they will be able to appropriately consume the required amounts of carbohydrate throughout the day then the strategically timed ingestion of carbohydrate may accelerate muscle glycogen re-synthesis. When prolonged endurance exercise is completed, carbohydrate ingestion may also help promote a favorable hormonal environment [ 65 , 66 ]. Studies employing resistance exercise that examined some aspect of carbohydrate timing are limited. Multiple studies have demonstrated that resistance exercise can significantly decrease muscle glycogen concentration [ 22 , 68 , 69 , 70 ], though these decreases are modest in comparison to exhaustive endurance exercise. However, the provision of pre-exercise carbohydrate to individuals performing resistance-style exercise in a moderately glycogen depleted state may not have an ergogenic effect. To date, one study has indicated that carbohydrate administration before and during bouts of resistance exercise can improve performance, but these ergogenic outcomes were only seen in the second session of resistance exercise performed on the same day [ 71 ]. In contrast, multiple studies have failed to report an improvement in resistance exercise performance [ 72 , 73 , 74 ]. One study involving pre-exercise and during exercise delivery of carbohydrate throughout a bout of resistance exercise has been shown to minimize the loss of muscle glycogen. Briefly, study participants were given a carbohydrate dose of 1. Athletes are encouraged to continue consuming small amounts of a carbohydrate solution or small snacks bars, gels, etc. to maintain liver glycogen levels and to help prevent hypoglycemia. Ingestion of carbohydrate during endurance type exercise maintains blood glucose levels, spares glycogen [ 75 ], and will likely enhance performance. Post-exercise consumption of carbohydrate is necessary and in situations where minimal recovery time is available, aggressive carbohydrate feeding is recommended. Although preliminary, initial work in intermittent, high-intensity activities suggest that carbohydrate timing may support metabolic outcomes, while performance results remain mixed, as do studies involving resistance exercise. For further inquiry, excellent reviews on the topic of carbohydrate and performance are available [ 20 , 21 , 48 , 49 , 76 ]. In a crossover fashion, participants ingested either a 7. When protein was added to carbohydrate, endurance was significantly improved. The same research group [ 79 ] used a nutrient gel and again reported that ingestion of a carbohydrate 0. Furthermore, the addition of protein to carbohydrate has been shown to increase the speed of glycogen recovery when a short recovery window is available or if sub-optimal amounts of carbohydrate have been delivered and can also help to reduce symptoms of muscle damage [ 80 ]. Notably, no studies have demonstrated that addition of protein to carbohydrate to a pre-exercise feeding in these amounts may hinder exercise performance. Similarly, Rustad and colleagues [ 81 ] reported that adding protein 0. To support recovery upon completion of exercise bouts that can deplete stored fuels and may cause significant damage to the muscle tissue, post-exercise nutrient timing strategies are of great interest. Ivy et al. These findings replicated previous findings [ 83 ] by this research group and led them to conclude that the addition of protein favorably promoted early phases of glycogen recovery. Berardi et al. As more research has been completed on the topic, the potential benefits of adding protein have been questioned. For example, Jentjens and colleagues [ 63 ] failed to show an improvement in muscle glycogen restoration with a combination of carbohydrate 1. Howarth and colleagues [ 86 ] later came to a similar conclusion regarding the addition of protein and extended these findings also to report that a higher dose of carbohydrate 1. For example, Kraemer and colleagues [ 87 ] had participants ingest a combination of carbohydrate, protein, and fat or an isoenergetic maltodextrin placebo for seven days before two consecutive days of resistance exercise. Moreover, markers of muscle damage e. A few years later, however, Fujita and colleagues [ 90 ] attempted to replicate their study findings and instead determined that MPS rates were similar between pre-exercise and post-exercise ingestion. While many people use the Fujita paper to discount the pre-exercise period, it should be noted that significant increases in MPS rates occurred when nutrients were administered before and after the resistance training bout in comparison to a non-energetic control suggesting that nutrient delivery itself , as opposed to timing of delivery, should be a larger priority. A later study by Bird et al. Using a crossover study design, participants also ingested a placebo that consisted of water flavored with a non-nutritive sweetener in similar volumes at the same times. They reported that delivering nutrients versus none at all did significantly increase the volume of exercise completed and reduced concentrations of serum proteins indicative of muscle damage. Bird et al. While these findings are encouraging, the studies are limited by the dosage of EAA provided as other studies have indicated that higher EAA doses up to 12 g may maximally stimulate MPS. As such, future research in this area should identify if different doses of EAA or combining a carbohydrate solution with varying doses of intact proteins consumed during resistance exercise bouts can further impact performance and resistance training adaptations. In this respect, when sufficient protein is supplied, it may be that carbohydrate has no additional adaptive benefit. As an example of this, Hulmi and colleagues [ 97 ] showed no benefit in resistance training adaptations when a combination of maltodextrin carbohydrate Changes in strength, hypertrophy, and body composition were assessed, and significant increases in lean body mass, 1RM strength, type II muscle fiber cross-sectional area, and higher muscle creatine and glycogen levels were found when the supplements were consumed immediately before and after workouts as opposed to consuming them in the morning and evening. Furthermore, Cribb and Hayes also provided creatine while the other studies did not, which has been shown in multiple investigative scenarios to augment the muscular adaptations seen while resistance training [ 98 , 99 , ]. Specifically, insulin promotes anti-catabolic effects in muscle [ ], thereby shifting protein balance to favor anabolism. This would suggest that post-workout carbohydrate supplementation likely exerts minimal influence from a muscle development standpoint provided adequate protein is consumed. However, when optimal carbohydrate is delivered the impact of adding protein irrespective of when it is provided appears to offer little to no additional benefit on endurance or resistance exercise performance as well as the recovery of reduced muscle glycogen. Much like the work on glycogen recovery, studies involving resistance training and optimization of adaptations seen from resistance training also point towards a higher priority being given towards the total amount of protein consumed during the day. Therefore, if total protein needs are met, the importance of adding carbohydrate and even more so in a timed fashion may be limited. A key point of discussion, however, lies with whether or not total energy needs are also being met, particularly in athletes undergoing large volumes of training and more so in those athletes that have high amounts of lean as well as body mass. In these situations, it certainly remains possible that the addition of carbohydrate to a protein feeding may help the athlete achieve an appropriate energy intake, which certainly may go on to impact the extent to which adaptations occur. In response to EAA ingestion and independent of leucine content, MPS rates and several signaling proteins related to muscle hypertrophy i. were significantly increased. While more research certainly needs to be conducted to better identify the potential impact and role of protein intake before endurance exercise, the priority for an endurance athlete in the hours leading up to competition should be focused on appropriate carbohydrate intake to fully maximize endogenous production of glycogen. As with endurance exercise, the majority of studies that have employed some form of protein or amino acid ingestion before bouts of resistance exercise have done so in conjunction with an identical dose during the post-exercise period as well. For example, Tipton and colleagues [ ] used an acute resistance exercise and feeding model to report that MPS rates were similar when a g dose of whey protein was ingested immediately before or immediately after a bout of lower body resistance training. Andersen et al. In this study, participants were randomized to ingest either 25 g of a protein blend In the group that consumed the protein-amino acid blend, type I and type II muscle fibers experienced a significant increase in size. Also, the protein-amino acid group experienced a significant increase in squat jump height while no changes occurred in the carbohydrate group. Using a similar study design, Hoffman and colleagues [ ] had collegiate football players who had been regularly performing resistance-training ingest 42 g of hydrolyzed collagen protein either immediately before and immediately after exercise, or in the morning and evening over the course of ten weeks of resistance training. In this study, the timing of protein intake did not impact changes in strength, power and body composition experienced from the resistance-training program. When examining the discrepant findings, one must consider a few things. First, the protein source in the Hoffman et al. study was mostly a collagen hydrolysate i. Finally, the study participants in the Andersen et al. More recently, Schoenfeld and colleagues [ ] published the first longitudinal study to directly compare the effects of ingesting 25 g of whey protein isolate either immediately before or immediately after each workout. This study is significant as it is the first investigation to attempt to compare pre versus post-workout ingestion of protein. The authors raised the question that the size, composition, and timing of a pre-exercise meal may impact the extent to which adaptations are seen in these studies. However, a key limitation of this investigation is the very limited training volumes these subjects performed. The total training sessions over the week treatment period was 30 sessions i. One would speculate that the individuals who would most likely benefit from peri-workout nutrition are those who train at much higher volumes. For instance, American collegiate athletes per NCAA regulations NCAA Bylaw 2. Thus, the average college athlete trains more in two weeks than most subjects train during an entire treatment period in studies in this category. In one of the only studies to use older participants, Candow and colleagues [ 15 ] assigned 38 men between the ages of 59—76 years to ingest a 0. While protein administration did favorably improve resistance-training adaptations, the timing of protein before or after workouts did not invoke any differential change. An important point to consider with the results of this study is the sub-optimal dose of protein approximately 26 g of whey protein versus the known anabolic resistance that has been demonstrated in the skeletal muscle of elderly individuals [ ]. In this respect, the anabolic stimulus from a g dose of whey protein may not have sufficiently stimulated muscle protein synthesis or have been of appropriate magnitude to induce differences between conditions. Clearly, more research is needed to determine if a greater dose of protein delivered before or after a workout may exert an impact on adaptations seen during resistance training in an elderly population. Limited studies are available that have examined the effect of providing protein throughout an acute bout of resistance exercise, particularly studies designed to explicitly determine if protein administration during exercise was more favorable than other times of administration. However, when examined over the course of 12 weeks, the increases in fiber size seen after ingesting a solution containing 6 g of EAA alone was less than when it was combined with carbohydrate [ 96 ]. The post-exercise time period has been aggressively studied for its ability to heighten various training outcomes. While a large number of acute exercise and nutrient administration studies have provided multiple mechanistic explanations for why post-exercise feeding may be advantageous [ , , , , ], other studies suggest this study model may not be directly reflective of adaptations seen over the course of several weeks or months [ ]. As highlighted throughout the pre-exercise protein timing section, the majority of studies that have examined some aspect of post-exercise protein timing have done so while also administering an identical dose of protein immediately before each workout [ 16 , , , ]. These results, however, are not universal as Hoffman et al. Of note, participants in the Hoffman study were all highly-trained collegiate athletes who reported consuming a hypoenergetic diet. Candow et al. As mentioned previously, it is possible that the dose of protein may not have been an appropriate amount to properly stimulate anabolism. In this respect, a small number of studies have examined the impact of solely ingesting protein after exercise. As discussed earlier, Tipton and colleagues [ ] used an acute model to determine changes in MPS rates when a g bolus of whey protein was ingested immediately before or immediately after a single bout of lower-body resistance training. MPS rates were significantly, and similarly, increased under both conditions. Until recently, the only study that examined the effects of post-exercise protein timing in a longitudinal manner was the work of Esmarck et al. In this study, 13 elderly men average age of 74 years consumed a small combination of carbohydrates 7 g , protein 10 g and fat 3 g either immediately within 30 min or 2 h after each bout of resistance exercise done three times per week for 12 weeks. Changes in strength and muscle size were measured, and it was concluded that ingesting nutrients immediately after each workout led to greater improvements in strength and muscle cross-sectional area than when the same nutrients were ingested 2 h later. While interesting, the inability of the group that delayed supplementation but still completed the resistance training program to experience any measurable increase in muscle cross-sectional area has led some to question the outcomes resulting from this study [ 5 , ]. Further and as discussed previously with the results of Candow et al. Schoenfeld and colleagues [ ] published results that directly examined the impact of ingesting 25 g of whey protein immediately before or immediately after bouts of resistance-training. All study participants trained three times each week targeting all major muscle groups over a week period, and the authors concluded no differences in strength and hypertrophy were seen between the two protein ingestion groups. These findings lend support to the hypothesis that ingestion of whey protein immediately before or immediately after workouts can promote improvements in strength and hypertrophy, but the time upon which nutrients are ingested does not necessarily trump other feeding strategies. Reviews by Aragon and Schoenfeld [ ] and Schoenfeld et al. The authors suggested that when recommended levels of protein are consumed, the effect of timing appears to be, at best, minimal. Indeed, research shows that muscles remain sensitized to protein ingestion for at least 24 h following a resistance training bout [ ] leading the authors to suggest that the timing, size and composition of any feeding episode before a workout may exert some level of impact on the resulting adaptations. In addition to these considerations, recent work by MacNaughton and colleagues [ ] reported that the acute ingestion of a g dose versus g of whey protein resulted in significantly greater increases in MPS in young subjects who completed an intense, high volume bout of resistance exercise that targeted all major muscle groups. Notwithstanding these conclusions, the number of studies that have truly examined a timing question is rather scant. Moreover, recommendations must capture the needs of a wide range of individuals, and to this point, a very small number of studies have examined the impact of nutrient timing using highly trained athletes. From a practical standpoint, some athletes may struggle, particularly those with high body masses, to consume enough protein to meet their required daily needs. As a starting point, it is important to highlight that most of the available research on this topic has largely used non-athletic, untrained populations except two recent publications using trained men and women [ , ]. Whether or not these findings apply to highly trained, athletic populations remains to be seen. Changes in weight loss and body composition were compared, and slightly greater weight loss occurred when the majority of calories was consumed in the morning. As a caveat to what is seemingly greater weight loss when more calories are shifted to the morning meals, higher amounts of fat-free mass were lost as well, leading to questions surrounding the long-term efficacy of this strategy regarding weight management and metabolic activity. Notably, this last point speaks to the importance of evenly spreading out calories across the day and avoiding extended periods of time where no food, protein in particular, is consumed. A large observational study [ ] examined the food intake of free-living individuals males and females ,and a follow-up study from the same study cohort [ ] reported that the timing of food consumption earlier vs. later in the day was correlated to the total daily caloric intake. Wu and colleagues [ ] reported that meals later in the day lead to increased rates of lipogenesis and adipose tissue accumulation in an animal model and, while limited, human research has also provided support. Previously it has been shown that people who skip breakfast display a delayed activation of lipolysis along with an increase in adipose tissue production [ , ]. More recently, Jakubowicz and colleagues [ ] had overweight and obese women consume cal each day for a week period. Approximately 2. While these results provide insight into how calories could be more optimally distributed throughout the day, a key perspective is that these studies were performed in sedentary populations without any form of exercise intervention. Thus, their relevance to athletes or highly active populations might be limited. Furthermore, the current research approach has failed to explore the influence of more evenly distributed meal patterns throughout the day. Meal frequency is commonly defined as the number of feeding episodes that take place each day. For years, recommendations have indicated that increasing meal frequency may serve as an effective way to influence weight loss, weight maintenance, and body composition. These assertions were based upon the epidemiological work of Fabry and colleagues [ , ] who reported that mean skinfold thickness was inversely related to the frequency of meals. One of these studies involved overweight individuals between 60 and 64 years of age while the other investigation involved 80 participants between the ages of 30—50 years of age. An even larger study published by Metzner and colleagues [ ] reported that in a sample of men and women between 35 and 60 years of age, meal frequency and adiposity were inversely related. While intriguing, the observational nature of these studies does not agree with more controlled experiments. For example, a study by Farshchi et al. The irregular meal pattern was found to result in increased levels of appetite, and hunger leading one to question if the energy provided in each meal was inadequate or if the energy content of each meal could have been better matched to limit these feelings while still promoting weight loss. Furthermore, Cameron and investigators [ ] published what is one of the first studies to directly compare a greater meal frequency to a lower frequency. In this study, 16 obese men and women reduced their energy intake by kcals per day and were assigned to one of two isocaloric groups: one group was instructed to consume six meals per day three traditional meals and three snacks , while the other group was instructed to consume three meals per day for an eight-week period. Changes in body mass, obesity indices, appetite, and ghrelin were measured at the end of the eight-week study, and no significant differences in any of the measured endpoints were found between conditions. These results also align with more recent results by Alencar [ ] who compared the impact of consuming isocaloric diets consisting of two meals per day or six meals per day for 14 days in overweight women on weight loss, body composition, serum hormones ghrelin, insulin , and metabolic glucose markers. No differences between groups in any of the measured outcomes were observed. A review by Kulovitz et al. Similar conclusions were drawn in a meta-analysis by Schoenfeld and colleagues [ ] that examined the impact of meal frequency on weight loss and body composition. Although initial results suggested a potential advantage for higher meal frequencies on body composition, sub-analysis indicated that findings were confounded by a single study, casting doubt as to whether the strategy confers any beneficial effects. From this, one might conclude that greater meal frequency may, indeed, favorably influence weight loss and body composition changes if used in combination with an exercise program for a short period of time. Certainly, more research is needed in this area, particularly studies that manipulate meal frequency in combination with an exercise program in non-athletic as well as athletic populations. Finally, other endpoints related to meal frequency i. may be of interest to different populations, but they extend beyond the scope of this position stand. An extension of altering the patterns or frequency of when meals are consumed is to examine the pattern upon which protein feedings occur. Moore and colleagues [ ] examined the differences in protein turnover and synthesis rates when participants ingested different patterns, in a randomized order, of an g total dose of protein over a h measurement period following a bout of lower body resistance exercise. One of the protein feeding patterns required participants to consume two g doses of whey protein isolate approximately 6 h apart. Another condition required the consumption of four, g doses of whey protein isolate every 3 h. The final condition required the participants to consume eight, g doses of whey protein isolate every 90 min. Rates of muscle protein turnover, synthesis, and breakdown were compared, and the authors concluded that protein turnover and synthesis rates were greatest when intermediate-sized g doses of whey protein isolate were consumed every 3 h. One of the caveats of this investigation was the very low total dose of protein consumed. Eighty grams of protein over a h period would be grossly inadequate for athletes performing high volumes of training as well as those who are extremely heavy e. A follow-up study one year later from the same research group determined myofibrillar protein synthesis rates after randomizing participants into three different protein ingestion patterns and examined how altering the pattern of protein administration affected protein synthesis rates after a bout of resistance exercise [ ]. Two key outcomes were identified. First, rates of myofibrillar protein synthesis rates increased in all three groups. Second, when four, g doses of whey protein isolate were consumed every 3 h over a h post-exercise period, significantly greater in comparison to the other two patterns of protein ingestion rates of myofibrillar protein synthesis occurred. In combining the results of both studies, one can conclude that ingestion of intermediate protein doses 20 g consumed every 3 h creates more favorable changes in both whole-body as well as myofibrillar protein synthesis [ , ]. Although both studies employed short-term methodology and other patterns or doses have yet to be examined, the results thus far consistently suggest that the timing or pattern in which high-quality protein is ingested may favorably impact net protein balance as well as rates of myofibrillar protein synthesis. An important caveat to these findings is that supplementation in most cases was provided in exclusion of other macronutrients over the duration of the study. Consumption of mixed meals delays gastric emptying and thus may result in different metabolic effects. Moreover, the fact that whey is a fast-absorbing protein source [ ] further confounds the ability to generalize results to traditional mixed-meal diets, as the potential for oxidation is increased with larger dosages, particularly in the absence of other macronutrients. Whether acute MPS responses translate to longitudinal changes in hypertrophy or fiber composition also remains to be determined [ ]. Protein pacing involves the consumption of 20—40 g servings of high-quality protein, from both whole food and protein supplementation, evenly spaced throughout the day, approximately every 3 h. The first meal is consumed within 60 min of waking in the morning, and the last meal is eaten within 3 h of going to sleep at night. Arciero and colleagues [ , ] have most recently demonstrated increased muscular strength and power in exercise-trained physically fit men and women using protein pacing compared to ingestion of similar sized meals at similar times but different protein contents, both of which included the same multi-component exercise training during a week intervention. In support of this theory one can point to the well characterized changes seen in peak MPS rates within 90 min after oral ingestion of protein [ ] and the return of MPS rates to baseline levels in approximately 90 min despite elevations in serum amino acid levels [ ]. Thus if efficacious protein feedings are placed too close together it remains possible that the ability of skeletal muscle anabolism to be fully activated might be limited. While no clear consensus exists as to the acceptance of this theory, conflicting findings exist between longitudinal studies that did provide protein feedings in close proximity to each other [ 16 , , ], making this an area that requires more investigation. Finally, while the mechanistic implications of pulsed vs. bolus protein feedings and their effect on MPS rates may help ultimately guide application, the practical importance has yet to be demonstrated. Eating before sleep has long been controversial [ , , ]. However, methodological considerations in the original studies such as the population used, time of feeding, and size of the pre-sleep meal confounds any conclusions that can be drawn. Recent work using protein-centric beverages consumed min before sleep and 2 h after the last meal dinner have identified pre-sleep protein consumption as advantageous to MPS, muscle recovery, and overall metabolism in both acute and long-term studies [ , ]. For example, data indicate that 30—40 g of casein protein ingested min prior to sleep [ ] or via nasogastric tubing [ ] increased overnight MPS in both young and old men, respectively. Likewise, in an acute setting, 30 g of whey protein, 30 g of casein protein, and 33 g of carbohydrate consumption min pre-sleep resulted in elevated morning resting metabolic rate in fit young men compared to a non-caloric placebo [ ]. Of particular interest is that Madzima et al. This infers that casein protein consumed pre-sleep maintains overnight lipolysis and fat oxidation. This finding was verifiedwhen Kinsey et al. It was concluded that pre-sleep casein did not blunt overnight lipolysis or fat oxidation. Similar to Madzima et al. Of note, it appears that previous exercise training completely ameliorates any rise in insulin when eating at night before sleep [ ] and the combination of pre-sleep protein and exercise has been shown to reduce blood pressure and arterial stiffness in young obese women with prehypertension and hypertension [ ]. To date, only two studies involving nighttime protein have been carried out for longer than four weeks. Snijders et al. The group receiving the protein-centric supplement each night before sleep had greater improvements in muscle mass and strength over the weeks. Of note, this study was non-nitrogen balanced and the protein group received approximately 1. More recently, in a nitrogen-balanced design using young healthy men and women, Antonio et al. All subjects maintained their usual exercise program. The authors reported no differences in body composition or performance between the morning and evening casein supplementation groups. A potential explanation for the lack of findings might stem from the already high intake of protein by the study participants before the study commenced. However, it is worth noting that although not statistically significant, the morning group added 0. Thus, it appears that protein consumption in the evening before sleep represents another opportunity to consume protein and other nutrients. Certainly more research is needed to determine if timing per se, or the mere addition of total daily protein can affect body composition or recovery via nighttime feeding. Nutrient timing is an area of research that continues to gather interest from researchers, coaches, and consumers. In reviewing the literature, two key considerations should be made. First, all findings surrounding nutrient timing require appropriate context because factors such as age, sex, fitness level, previous fueling status, dietary status, training volume, training intensity, program design, and time before the next training bout or competition can influence the extent to which timing may play a role in the adaptive response to exercise. Second, nearly all research within this topic requires further investigation. The reader must keep in perspective that in its simplest form nutrient timing is a feeding strategy that in nearly all situations may be helpful towards the promotion of recovery and adaptations towards training. This context is important because many nutrient timing studies demonstrate favorable changes that do not meet statistical thresholds of significance thereby leaving the reader to interpret the level of practical significance that exists from the findings. It is noteworthy that differences in real-world athletic performances can be so small that even strategies that offer a modicum of benefit are still worth pursuing. In nearly all such situations, this approach results in an athlete receiving a combination of nutrients at specific times that may be helpful and has not yet shown to be harmful. This perspective also has the added advantage of offering more flexibility to the fueling considerations a coach or athlete may employ. Using this approach, when both situations timed or non-timed ingestion of nutrients offer positive outcomes then our perspective is to advise an athlete to follow whatever strategy offers the most convenience or compliance if for no other reason than to deliver vital nutrients in amounts at a time that will support the physiological response to exercise. Finally, it is advisable to remind the reader that due to the complexity, cost and invasiveness required to answer some of these fundamental questions, research studies often employ small numbers of study participants. Also, for the most part studies have primarily evaluated men. This latter point is particularly important as researchers have documented that females oxidize more fat when compared to men, and also seem to utilize endogenous fuel sources to different degrees [ 28 , 29 , 30 ]. Furthermore, the size of potential effects tends to be small, and when small potential effects are combined with small numbers of study participants, the ability to determine statistical significance remains low. Nonetheless, this consideration remains relevant because it underscores the need for more research to better understand the possibility of the group and individual changes that can be expected when the timing of nutrients is manipulated. In many situations, the efficacy of nutrient timing is inherently tied to the concept of optimal fueling. Thus, the importance of adequate energy, carbohydrate, and protein intake must be emphasized to ensure athletes are properly fueled for optimal performance as well as to maximize potential adaptations to exercise training. High-intensity exercise particularly in hot and humid conditions demands aggressive carbohydrate and fluid replacement. Consumption of 1. The need for carbohydrate replacement increases in importance as training and competition extend beyond 70 min of activity and the need for carbohydrate during shorter durations is less established. Adding protein 0. Moreover, the additional protein may minimize muscle damage, promote favorable hormone balance and accelerate recovery from intense exercise. For athletes completing high volumes i. The use of a 20—g dose of a high-quality protein source that contains approximately 10—12 g of the EAA maximizes MPS rates that remain elevated for three to four hours following exercise. Protein consumption during the peri-workout period is a pragmatic and sensible strategy for athletes, particularly those who perform high volumes of exercise. Not consuming protein post-workout e. The impact of delivering a dose of protein with or without carbohydrates during the peri-workout period over the course of several weeks may operate as a strategy to heighten adaptations to exercise. Like carbohydrate, timing related considerations for protein appear to be of lower priority than the ingestion of optimal amounts of daily protein 1. In the face of restricting caloric intake for weight loss, altering meal frequency has shown limited effects on body composition. However, more frequent meals may be more beneficial when accompanied by an exercise program. The impact of altering meal frequency in combination with an exercise program in non-athlete or athlete populations warrants further investigation. It is established that altering meal frequency outside of an exercise program may help with controlling hunger, appetite and satiety. Nutrient timing strategies that involve changing the distribution of intermediate-sized protein doses 20—40 g or 0. One must also consider that other factors such as the type of exercise stimulus, training status, and consumption of mixed macronutrient meals versus sole protein feedings can all impact how protein is metabolized across the day. When consumed within 30 min before sleep, 30—40 g of casein may increase MPS rates and improve strength and muscle hypertrophy. In addition, protein ingestion prior to sleep may increase morning metabolic rate while exerting minimal influence over lipolysis rates. In addition, pre-sleep protein intake can operate as an effective way to meet daily protein needs while also providing a metabolic stimulus for muscle adaptation. Altering the timing of energy intake i. Kerksick C, Harvey T, Stout J, Campbell B, Wilborn C, Kreider R, Kalman D, Ziegenfuss T, Lopez H, Landis J, et al. International Society Of Sports Nutrition Position Stand: Nutrient Timing. J Int Soc Sports Nutr. Article PubMed PubMed Central CAS Google Scholar. Sherman WM, Costill DI, Fink WJ, Miller JM. Effect Of Exercise-Diet Manipulation On Muscle Glycogen And Its Subsequent Utilization During Performance. Int J Sports Med. Article CAS PubMed Google Scholar. Karlsson J, Saltin B. Diet, Muscle Glycogen, And Endurance Performance. J Appl Physiol. CAS PubMed Google Scholar. Ivy JL, Katz AL, Cutler CL, Sherman WM, Coyle EF. Muscle Glycogen Synthesis After Exercise: Effect Of Time Of Carbohydrate Ingestion. Cermak NM, Res PT, De Groot LC, Saris WH, Van Loon LJ. Protein Supplementation Augments The Adaptive Response Of Skeletal Muscle To Resistance-Type Exercise Training: A Meta-Analysis. Am J Clin Nutr. Marquet LA, Hausswirth C, Molle O, Hawley JA, Burke LM, Tiollier E, Brisswalter J. Periodization Of Carbohydrate Intake: Short-Term Effect On Performance. Article PubMed Google Scholar. Barry DW, Hansen KC, Van Pelt RE, Witten M, Wolfe P, Kohrt WM. Acute Calcium Ingestion Attenuates Exercise-Induced Disruption Of Calcium Homeostasis. Med Sci Sports Exerc. Article CAS PubMed PubMed Central Google Scholar. Haakonssen EC, Ross ML, Knight EJ, Cato LE, Nana A, Wluka AE, Cicuttini FM, Wang BH, Jenkins DG, Burke LM. The Effects Of A Calcium-Rich Pre-Exercise Meal On Biomarkers Of Calcium Homeostasis In Competitive Female Cyclists: A Randomised Crossover Trial. PLoS One. Shea KL, Barry DW, Sherk VD, Hansen KC, Wolfe P, Kohrt WM. Calcium Supplementation And Pth Response To Vigorous Walking In Postmenopausal Women. Sherk VD, Barry DW, Villalon KL, Hansen KC, Wolfe P, Kohrt WM. |
| Plant-Soil Interactions: Nutrient Uptake | Learn Science at Scitable | Moreover, different macronutrient ratios do not significantly affect how much total fat you lose in the long run. Ruminant trans fats, occurring naturally in meat and dairy products, do not need to be eliminated because they are present in such small quantities Suggested Citation Institute of Medicine. Results from other research groups [ 56 , 57 , 58 , 66 ] show that timing of protein near ± 2 h aerobic and anaerobic exercise training appears to provide a greater activation of the molecular signalling pathways that regulate myofibrillar and mitochondrial protein synthesis as well as glycogen synthesis. Carbohydrate Moderate to high intensity e. |
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