Alison B. Evert

Nutrition Therapy Recommendations for the Management of Adults With Diabetes

There is no standard meal plan or eating pattern that works universally for all people with diabetes. In order to be effective, nutrition therapy should be individualized for each patient/client based on his or her individual health goals; personal and cultural preferences; health literacy and numeracy; access to healthful choices; and readiness, willingness, and ability to change. Nutrition interventions should emphasize a variety of minimally processed nutrient dense foods in appropriate portion sizes as part of a healthful eating pattern and provide the individual with diabetes with practical tools for day-to-day food plan and behavior change that can be maintained over the long term.

Evidence-based diabetes nutrition therapy recommendations are effective: the key is individualization.

Current nutrition therapy recommendations for the prevention and treatment of diabetes are based on a systematic review of evidence and answer important nutrition care questions. First, is diabetes nutrition therapy effective? Clinical trials as well as systematic and Cochrane reviews report a ~1%–2% lowering of hemoglobin A1c values as well as other beneficial outcomes from nutrition therapy interventions, depending on the type and duration of diabetes and level of glycemic control. Clinical trials also provide evidence for the effectiveness of nutrition therapy in the prevention of diabetes. Second, are weight loss interventions important and when are they beneficial? Modest weight loss is important for the prevention of type 2 diabetes and early in the disease process. However, as diabetes progresses, weight loss may or may not result in beneficial glycemic and cardiovascular outcomes. Third, are there ideal percentages of macronutrients and eating patterns that apply to all persons with diabetes? There is no ideal percentage of macronutrients and a variety of eating patterns has been shown to be effective for persons with diabetes. Treatment goals, personal preferences (eg, tradition, culture, religion, health beliefs, economics), and the individual’s ability and willingness to make lifestyle changes must all be considered by clinicians and/or educators when counseling and educating individuals with diabetes. A healthy eating pattern emphasizing nutrient-dense foods in appropriate portion sizes, regular physical activity, and support are priorities for all individuals with diabetes. Reduced energy intake for persons with prediabetes or type 2 diabetes as well as matching insulin to planned carbohydrate intake are intervention to be considered. Fourth, is the question of how to implement nutrition therapy interventions in clinical practice. This requires nutrition care strategies.

Academy of Nutrition and Dietetics Nutrition Practice Guideline for Type 1 and Type 2 Diabetes in Adults: Nutrition Intervention Evidence Reviews and Recommendations

T HE ACADEMY OF NUTRITION and Dietetics (Academy) Nutrition Practice Guideline (NPG) for Type 1 and Type 2 Diabetes in Adults is a newly developed guideline. It has also been published in the Academy’s Evidence Analysis Library (EAL). The NPG updates the 2008 Diabetes Type 1 and 2 Evidence-Based NPG for Adults. Evidence for the effectiveness of medical nutrition therapy (MNT) provided by registered dietitian nutritionists (RDNs) and the integration of MNT into the Nutrition Care Process is reviewed in an accompanying article. MNT plays a critical role in managing both types of diabetes, reducing the potential complications related to poor glycemic, lipid, and blood pressure control, and improving quality of life. The need to provide clients with evidence-based nutrition care is essential for providing optimum diabetes care. Diabetes MNT recommendations for adults are often more related to the management of diabetes (nutrition therapy alone, glucose-lowering medications, and/or insulin) than the type of diabetes (type 1 or type 2). Therefore, the Academy’s NPG is for adults with type 1 or type 2 diabetes. When a recommendation is specific for an adult with type 1 or type diabetes it is noted. This article summarizes nutrition interventions for type 1 and type 2 diabetes in adults (the EAL review and conclusion statements), states the evidence-based NPG recommendations, reviews research published after the completion of the EAL review (through June 2016), and identifies limitations and gaps in knowledge that require further research.

Lifestyle Intervention: Nutrition Therapy and Physical Activity

Diabetes now affects more than 29 million Americans, and more than 9 million of these people do not know they have diabetes. In adults, type 2 diabetes accounts for about 90% to 95% of all diagnosed cases of diabetes and is the focus of this article. Lifestyle intervention is part of the initial treatment as well as the ongoing management of type 2 diabetes. Lifestyle intervention encompasses a healthful eating plan, physical activity, and often medication to assist in achievement of glucose, lipid, and blood pressure goals. Patient education and self-care practices are also important aspects of disease management.

Treatment of Mild Hypoglycemia.

> “Let food be thy medicine and medicine be thy food.” > > —Hippocrates It has been well established by studies such as the landmark Diabetes Control and Complications Trial (DCCT) that metabolic control delays the development and progression of microvascular complications in adults with type 1 diabetes.1 Unfortunately, improvement in metabolic control is associated with an increased incidence of treatment-induced hypoglycemia. This is a common side effect of insulin, as well as the insulin secretagogues frequently used in the treatment of type 2 diabetes.2 As insulin secretion diminishes in type 2 diabetes, hypoglycemia becomes more frequent and limiting. Five years after initiation of insulin therapy, the rate of severe hypoglycemia is reported to be as high as 35–70 episodes per 100 patient-years, higher than that in type 1 diabetes.3,4 Abnormal glucose counterregulation (and hypoglycemia unawareness) progresses based on the progression of insulin deficiency. Thus, because type 2 diabetes is more prevalent than type 1 diabetes, most episodes of hypoglycemia occur in people with type 2 diabetes.2 In both type 1 and type 2 diabetes, counterregulatory responses to hypoglycemia steadily decline with frequent and repetitive episodes.2 This can become a vicious circle; a hypoglycemia episode impairs defenses against a subsequent episode, and thus hypoglycemia can result in recurrent hypoglycemia. Hypoglycemia causes increased morbidity in most people with type 1 diabetes and in many with a long duration of type 2 diabetes and is sometimes fatal.2 There is growing evidence that older adults with known cardiovascular disease (CVD)5–8 and very young children who cannot independently recognize low glucose levels may be particularly vulnerable to adverse events associated with hypoglycemia.9,10 Findings such as these led a workgroup from the American Diabetes Association (ADA) and The Endocrine Society (TES) to publish a …

New Diabetes Nutrition Therapy Recommendations: What You Need to Know

The American Diabetes Association (ADA) has long recognized the integral role of nutrition therapy in overall diabetes management and recommends that each person with diabetes receive an individualized eating plan that has been developed in collaboration with his or her health care provider (HCP).1 To ensure that members of the health care team are providing up-to-date, evidence-based clinical practice recommendations, the ADA issues official position statements on scientific or medical issues related to diabetes. Recently, the ADA published a position statement titled “Nutrition Therapy Recommendations for the Management of Adults With Diabetes.”2 These recommendations replace those in previous position statements. This article reviews the development process for the 2013 nutrition recommendations, shares highlights from those guidelines, and discusses priority topics in the publication. The 2013 ADA nutrition statement was written at the request of the ADA Professional Practice Committee. In August 2012, the ADA convened a committee of nutrition experts in clinical practice and research, as well as other members of the diabetes health care team (a registered nurse/advanced practice nurse practitioner, a physician, and a pharmacist) to review the scientific literature and develop recommendations. The multidisciplinary committee followed the Institute of Medicine (IOM) Standards for Trustworthy Clinical Practice Guidelines.3 Based on the IOM standards, conflict of interest disclosures were obtained before confirmation of appointment of the co-chairs and the members of the committee/writing group. Development of the position statement was funded from ADA general revenues and not with any corporate or industry financial support. The committees work on the position statement began with an introductory conference call. The group reviewed an outline for the statement and assigned sections to specific members. Committee members were instructed to conduct thorough literature searches and create evidence tables for all of the topics included in the statement. Inclusion criteria for …

Why Weight Loss Maintenance Is Difficult

IN BRIEF This article reviews studies related to biological mechanisms that make weight loss maintenance difficult. Approximately 50% of weight variance is reported to be determined by genetics and 50% by the environment (energy-dense foods and reduced physical activity). Body weight is tightly regulated by hormonal, metabolic, and neural factors. Hormonal adaptations (decreases in leptin, peptide YY, cholecystokinin, and insulin and increases in ghrelin, glucagon-like peptide 1, gastric inhibitory polypeptide, and pancreatic polypeptide) encourage weight gain after diet-induced weight loss and continue for at least 1 year after initial weight reduction. Weight loss also results in adaptive thermogenesis (decreased resting metabolic rate), which is also maintained long-term. Neural factors such as dopamine also signal the need to respond to an increased desire for fatty foods after weight loss.

Role of Health Educators in Assisting Youth and Adolescents with Diabetes

Abstract Management of diabetes in children requires balancing nutrition, physical activity and medication on a daily basis in order to achieve blood glucose targets. The health educator can assist children and their families in meeting their diabetes management goals by better understanding the current recommendations and tasks involved to achieve them. Whereas children with type 1 diabetes require multiple injections of insulin per day or use of an insulin pump, children with type 2 diabetes may require an oral medication, insulin or both. Nutrition and physical activity recommendations are similar for children with diabetes as they are for all healthy children. Meal planning for children with diabetes usually involves a method of carbohydrate counting, since this is the main nutrient that raises blood glucose. Short term management outcomes for children with diabetes include the prevention of hypo- and hyperglycemia, while long term outcomes include the prevention of micro and macro-vascular complications.

Aanbevelingen voor voedingstherapie bij de behandeling van volwassenen met diabetes

SamenvattingEr is geen standaard maaltijdplan of eetpatroon dat overal voor alle diabetespatienten werkt.1 Wil voedingstherapie effectief zijn dan dient die therapie op de individuele diabetespatiënt te worden afgestemd op basis van zijn of haar persoonlijke gezondheidsdoelen, persoonlijke en culturele voorkeuren,7,8 het vermogen om gezondheidsgegevens te lezen en te berekenen,9,10 toegang te hebben tot gezonde keuzes11,12 en de bereidheid en het vermogen tot verandering. Voedingsinterventies moeten de nadruk leggen op diversiteit in minimaal bewerkte nutriëntrijke voedingsmiddelen en geschikte porties als onderdeel van een gezond eetpatroon. En ze moeten diabetespatiënten voorzien van praktische instrumenten voor de dagelijkse voedselplanning en voor gedragsverandering die ook op de lange termijn standhoudt.AbstractThere is no standard meal plan or eating pattern that works universally for all people with diabetes.1 In order to be effective, nutrition therapy should be individualized for each patient/client based on his or her individual health goals; personal and cultural preferences;7,8 health literacy and numeracy;9,10 access to healthful choices;11,12 and readiness, willingness and ability to change. Nutrition interventions should emphasize a variety of minimally processed nutrientdense foods in appropriate portion sizes as part of a healthful eating pattern and provide the individual with diabetes with practical tools for day-to-day food plan and behavior change that can be maintained over the long term.

Response to Comments on Evert et al. Nutrition Therapy Recommendations for the Management of Adults With Diabetes. Diabetes Care 2013;36:3821–3842

Dr. Sigal (1) and Jardine et al. (2) summarize several observational studies showing that consumption of animal products is related to incidence of type 2 diabetes. Nutrition therapy for the prevention of type 2 diabetes is an important topic that has substantial evidence supporting its effectiveness based on randomized controlled trials (RCTs) (3,4). The focus of the position statement, however, was on the management of patients already diagnosed with type 1 or type 2 diabetes (5). Therefore, the studies summarized in Sigal and Jardine et al. were excluded from the literature review. While observational studies were included in the literature review, the position statement placed emphasis on RCTs because of the biases inherent to observational research. For example, people who consume larger amounts of meat may have other behaviors or characteristics that confound the relationship between meat intake and disease. As an example, in …