In the Journals

ADA: Medical nutrition therapy ‘fundamental’ in diabetes management

All adults with diabetes or prediabetes should be referred to individualized, diabetes-focused medical nutrition therapy at diagnosis and as needed throughout the lifespan as part of an overall care plan with the goal of improving disease outcomes, according to a new consensus statement released by the American Diabetes Association.

William S. Yancy

Prescribing a “one-size-fits-all” eating plan for people with diabetes is unrealistic given the broad spectrum of people affected by diabetes and prediabetes, their cultural backgrounds, personal preferences and comorbidities, William S. Yancy, MD, MHS, FTOS, associate professor of medicine at Duke University School of Medicine in Durham, North Carolina, and colleagues wrote in the statement. The ADA instead emphasizes that individualized medical nutrition therapy is “fundamental” in the overall diabetes management plan, and the need for medical nutrition therapy should be reassessed frequently by health care providers in collaboration with patients, especially during times of changing health status and life stages. The statement defines medical nutrition therapy as an evidence-based application of the nutrition care process provided by a registered dietitian nutritionist. Essential components include assessment, nutrition diagnosis, interventions (education and counseling) and monitoring with ongoing follow-up to support lifestyle changes.

“This consensus report recognized multiple varied dietary strategies can be effective rather than a one-diet-fits-all approach,” Yancy told Endocrine Today. “This gives options to the patient and the practitioner and means that practitioners should familiarize themselves with the various options in order to accommodate patients’ unique needs to maximize success. The statement also recognized that dietary carbohydrate is the most important contributor to blood glucose, and weight loss, when appropriate, is one of the most potent strategies for diabetes management.”

The report, which updates the ADA’s 2014 position statement on nutrition therapy for adults with diabetes, now includes adults with prediabetes and stresses individualized nutrition plans.

“Prediabetes is becoming increasingly recognized in medical practice, and the evidence shows that it responds very well to nutritional changes and weight loss, more so than it does to medication,” Yancy said. “Given this and the increasing prevalence of type 2 diabetes, the ADA wanted to make sure to include guidance for practitioners who are working with people who are at risk for developing type 2 diabetes.”

No ‘perfect’ plan

The statement provides an overview of several popular eating patterns and their potential benefits, including the Mediterranean-style diet, vegetarian or vegan eating patterns, low-fat, low carbohydrate, paleo eating plan, intermittent fasting and the Dietary Approaches to Stop Hypertension (DASH) diet. The authors noted that, rather than focus on specific eating plans, health care providers should instead focus on key factors that are common across eating patterns — emphasize nonstarchy vegetables, minimize added sugars and refined grains, and choose whole foods over highly processed foods whenever possible.

“All eating patterns include a range of more healthy vs. less healthy options: Lentils and sugar-sweetened beverages are both considered part of a vegan eating pattern; fish and processed red meats are both considered part of a low-carbohydrate eating pattern; and removing the bun from a fast food burger might make it part of a paleo eating pattern, but does not necessarily make it healthier,” the researchers wrote. “Further, studies comparing the same two or more eating patterns could easily differ in the investigators’ definition of the patterns, the effectiveness of the research team in fostering pattern adherence among study participants, the accuracy of assessing pattern adherence, study duration and participant population characteristics.”

Managing complications

Nutrition therapy that includes the development of an eating plan that can optimize blood glucose trends, blood pressure and lipid profile is important to help in the management of diabetes and could lower the risk for developing cardiovascular disease, the authors wrote. The statement recommends people with diabetes replace dietary saturated fats with monounsaturated and polyunsaturated fatty acids to help reduce LDL cholesterol. People with diabetes and prediabetes are also encouraged to consume less than 2,300 mg per day of sodium to reduce the risk for hypertension. Among patients with diabetic kidney disease, reducing the amount of dietary protein below the recommended daily allowance (0.8 g/kg body weight per day) does not meaningfully alter glycemic measures, according to the statement and may increase the risk for malnutrition.

“Evidence does not suggest that people with [diabetic kidney disease] need to restrict protein intake to less than the average protein intake,” the researchers wrote. “For people with [diabetic kidney disease] and macroalbuminuria, changing to a more soy-based source of protein may improve CVD risk factors, but does not appear to alter proteinuria.”

Reducing barriers

The authors noted that most people with diabetes do not receive any nutrition therapy or formal diabetes education. To improve access, the statement recommends that technology-enabled diabetes nutrition therapy be integrated with medical management, and community health workers and peer coaches be deployed to provide culturally appropriate, ongoing support and linked care coordination.

“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,” the researchers wrote. “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.”

The consensus report was produced by a panel of 14 experts including registered dietitian nutritionists, certified diabetes educators, endocrinologists, a primary care physician and a patient advocate. Nine additional peer experts in diabetes and the ADA’s Professional Practice Committee reviewed the consensus report. The panel performed a review of more than 600 nutrition manuscripts published between 2014 and 2018.

The consensus report was incorporated into the ADA’s Standards of Medical Care in Diabetes. – by Regina Schaffer

For more information:

William S. Yancy, MD, MHS, FTOS, can be reached at the Duke University Diet and Fitness Center, 501 Douglas Sr., Durham, NC 27705; email: will.yancy@duke.edu.

Disclosures: Yancy reports he has a consulting relationship with dietdoctor.com, which began after the consensus report was submitted to Diabetes Care. Please see the consensus statement for all authors’ relevant financial disclosures.

All adults with diabetes or prediabetes should be referred to individualized, diabetes-focused medical nutrition therapy at diagnosis and as needed throughout the lifespan as part of an overall care plan with the goal of improving disease outcomes, according to a new consensus statement released by the American Diabetes Association.

William S. Yancy

Prescribing a “one-size-fits-all” eating plan for people with diabetes is unrealistic given the broad spectrum of people affected by diabetes and prediabetes, their cultural backgrounds, personal preferences and comorbidities, William S. Yancy, MD, MHS, FTOS, associate professor of medicine at Duke University School of Medicine in Durham, North Carolina, and colleagues wrote in the statement. The ADA instead emphasizes that individualized medical nutrition therapy is “fundamental” in the overall diabetes management plan, and the need for medical nutrition therapy should be reassessed frequently by health care providers in collaboration with patients, especially during times of changing health status and life stages. The statement defines medical nutrition therapy as an evidence-based application of the nutrition care process provided by a registered dietitian nutritionist. Essential components include assessment, nutrition diagnosis, interventions (education and counseling) and monitoring with ongoing follow-up to support lifestyle changes.

“This consensus report recognized multiple varied dietary strategies can be effective rather than a one-diet-fits-all approach,” Yancy told Endocrine Today. “This gives options to the patient and the practitioner and means that practitioners should familiarize themselves with the various options in order to accommodate patients’ unique needs to maximize success. The statement also recognized that dietary carbohydrate is the most important contributor to blood glucose, and weight loss, when appropriate, is one of the most potent strategies for diabetes management.”

The report, which updates the ADA’s 2014 position statement on nutrition therapy for adults with diabetes, now includes adults with prediabetes and stresses individualized nutrition plans.

“Prediabetes is becoming increasingly recognized in medical practice, and the evidence shows that it responds very well to nutritional changes and weight loss, more so than it does to medication,” Yancy said. “Given this and the increasing prevalence of type 2 diabetes, the ADA wanted to make sure to include guidance for practitioners who are working with people who are at risk for developing type 2 diabetes.”

No ‘perfect’ plan

The statement provides an overview of several popular eating patterns and their potential benefits, including the Mediterranean-style diet, vegetarian or vegan eating patterns, low-fat, low carbohydrate, paleo eating plan, intermittent fasting and the Dietary Approaches to Stop Hypertension (DASH) diet. The authors noted that, rather than focus on specific eating plans, health care providers should instead focus on key factors that are common across eating patterns — emphasize nonstarchy vegetables, minimize added sugars and refined grains, and choose whole foods over highly processed foods whenever possible.

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“All eating patterns include a range of more healthy vs. less healthy options: Lentils and sugar-sweetened beverages are both considered part of a vegan eating pattern; fish and processed red meats are both considered part of a low-carbohydrate eating pattern; and removing the bun from a fast food burger might make it part of a paleo eating pattern, but does not necessarily make it healthier,” the researchers wrote. “Further, studies comparing the same two or more eating patterns could easily differ in the investigators’ definition of the patterns, the effectiveness of the research team in fostering pattern adherence among study participants, the accuracy of assessing pattern adherence, study duration and participant population characteristics.”

Managing complications

Nutrition therapy that includes the development of an eating plan that can optimize blood glucose trends, blood pressure and lipid profile is important to help in the management of diabetes and could lower the risk for developing cardiovascular disease, the authors wrote. The statement recommends people with diabetes replace dietary saturated fats with monounsaturated and polyunsaturated fatty acids to help reduce LDL cholesterol. People with diabetes and prediabetes are also encouraged to consume less than 2,300 mg per day of sodium to reduce the risk for hypertension. Among patients with diabetic kidney disease, reducing the amount of dietary protein below the recommended daily allowance (0.8 g/kg body weight per day) does not meaningfully alter glycemic measures, according to the statement and may increase the risk for malnutrition.

“Evidence does not suggest that people with [diabetic kidney disease] need to restrict protein intake to less than the average protein intake,” the researchers wrote. “For people with [diabetic kidney disease] and macroalbuminuria, changing to a more soy-based source of protein may improve CVD risk factors, but does not appear to alter proteinuria.”

Reducing barriers

The authors noted that most people with diabetes do not receive any nutrition therapy or formal diabetes education. To improve access, the statement recommends that technology-enabled diabetes nutrition therapy be integrated with medical management, and community health workers and peer coaches be deployed to provide culturally appropriate, ongoing support and linked care coordination.

“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,” the researchers wrote. “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.”

PAGE BREAK

The consensus report was produced by a panel of 14 experts including registered dietitian nutritionists, certified diabetes educators, endocrinologists, a primary care physician and a patient advocate. Nine additional peer experts in diabetes and the ADA’s Professional Practice Committee reviewed the consensus report. The panel performed a review of more than 600 nutrition manuscripts published between 2014 and 2018.

The consensus report was incorporated into the ADA’s Standards of Medical Care in Diabetes. – by Regina Schaffer

For more information:

William S. Yancy, MD, MHS, FTOS, can be reached at the Duke University Diet and Fitness Center, 501 Douglas Sr., Durham, NC 27705; email: will.yancy@duke.edu.

Disclosures: Yancy reports he has a consulting relationship with dietdoctor.com, which began after the consensus report was submitted to Diabetes Care. Please see the consensus statement for all authors’ relevant financial disclosures.

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