Hope Warshaw MMSc, RD, CDE, BC-ADM PRESENT Diabetes Contributing Nutrition Editor

Dear Colleague,

November is a busy month in the diabetes world with American Diabetes Month and World Diabetes Day on November 14th. I hope you’ve been using any and all vehicles you have to raise awareness about prediabetes and diabetes. Please encourage people to act now and take control.

This year November also marks the publication, in Diabetes Care, of the latest revision since 2008, of the Nutrition Recommendations for Adults with Diabetes from the American Diabetes Association.¹ This position paper is available online for all to view. In this NutriZine, I’ll dig in to these new recommendations to review the overarching themes and hot topics.

As the title indicates, this position paper focuses only on adults with type 1 and 2 diabetes. Not covered are prediabetes, gestational diabetes and children. Much, but not all, of the research included on macronutrients is based on findings from the 2012 systematic review Macronutrient, Food groups, and Eating Patterns in the Management of Diabetes.²

I’m pleased to note that this is the first time ever that the effort to revise the ADA nutrition recommendations was co-led by two dietitians – Alison Evert, MS, RD, CDE, Coordinator of Diabetes Education Programs at University of Washington Medical Center/ and Jackie Boucher, MS, RD, CDE, Vice President, Education at the Minneapolis Heart Institute Foundation. It’s my hunch that their leadership led to significant attention to the practical implementation of nutrition therapy.

Evert and Boucher graciously share a few of their insights about the paper in this NutriZine. “There’s more emphasis on eating patterns because, though there’s been decades of debate about the optimal macronutrient mix for diabetes, reality is people eat food and combinations of foods, they don’t eat nutrients in isolation,” says Boucher. Evert adds, “There’s greater focus on the importance of individualizing eating plans based on the person’s existing eating habits, food preferences, entire lifestyle and metabolic goals.”

In sum, this position paper stresses seven overarching themes which bring to light the evolution of nutrition research coupled with years of learning about how to help clients make critical changes in their eating patterns and lifestyle to achieve optimal clinical outcomes.

The ADA position paper covers the topics we’re used to reading about in past papers, from the optimal macronutrient mix, to details about the three macronutrients, glycemic index/load, micronutrients, alcohol, sodium, fructose, nonnutritive sweeteners and more. Next, I’ll cover a few of the hot topics or those with new information and thinking.

Eating/Dietary Patterns

This new section delves into the research on defining eating patterns. Dietary patterns are defined as combinations of foods or food groups which contain various nutrients, not single nutrients. People and families come to the diagnosis of diabetes with individual factors including their culture, traditions, food preference, timing of meals and snacks, etc., along with their willingness and ability to make changes. These must be factored into an individualized approach for successful intervention. Minimize forced changes in a person’s eating plan. Research, including from the POUNDS LOST study, shows it’s difficult for people to dramatically change their habits and food choices. Check out the NutriZine covering the POUNDS LOST study.

Macronutrient Mix and Carbohydrate Intake

The net result from research is, there’s no one ideal percent of calories from carbohydrate, protein and fat for everyone with diabetes. Bottom lines: a range of carbohydrate intake, from about 45% of calories to 65%, can help people achieve metabolic goals. To meet nutrient needs, especially at lower calorie levels, people need to eat at least 45% of calories as carbohydrate (Read NutriZine dedicated to carbohydrate intake. True, carbohydrate intake has a direct effect on postprandial plasma glucose and is the primary macronutrient of concern in glycemic management. This shouldn’t be interpreted as the rationale to limit carbohydrate as it frequently seems to be. It should be used to point out that a healthy carbohydrate intake (> 45%) requires the presence of adequate endogenous or exogenous insulin.

Glycemic Index/Load

Some research shows that substituting low-glycemic load foods for higher-glycemic load foods can modestly improve glycemic control (A1c change of ~0.2-0.5%). Other studies show NO glycemic or CVD benefits. Challenges of this research were noted, particularly the independent effect of higher fiber intake usually seen with lower glycemic index diets. Within this discussion, the paper encouraged people to eat at least the amount of fiber and whole grains recommended for the general public. Reality is this can’t be achieved with a carbohydrate intake below 45% of calories, especially at lower calorie levels.

Weight Management

Three of four people with type 2 are overweight and half are obese. So, what works? With each long term trial (and there have not been many) we know more. No one eating pattern, from low carbohydrate, to Mediterranean to vegan, works for everyone. Overall and with a variety of eating plans, research shows that modest weight loss (1.9 – 8.4kg), regular physical activity, a focus on behavior change and frequent contact with RDs (counseling/support) are necessary features to demonstrate consistent beneficial long term outcomes. Weight loss doesn’t always improve glycemia, but is most likely to have an impact early in the disease progression. “Research shows collaboration between the client and clinician is essential to integrate behavior change strategies to promote modest, realistic weight loss,” says Evert. Studies show even modest weight loss, especially early after the diagnosis of type 2, can offer numerous health benefits.

Let me conclude this download of the ADA nutrition recommendations with a summary from Boucher, "The recommendations, with the supportive research, lead to the conclusion that nutrition therapy in diabetes is effective if it’s provided as emphasized in these guidelines.”

Do you know that nearly simultaneously another set of clinical practice guidelines on the topic of nutrition and diabetes were published? Yes! Just about a week after the ADA nutrition recommendations were initially released in early October, the Clinical Practice Guideline, entitled Healthy Eating for the Prevention and Treatment of Metabolic and Endocrine Diseases in Adults, was published online by the American Association of Clinical Endocrinologist and The Obesity Society.

It’s interesting to compare these two sets of guidelines. Both cover similar research terrain and offer similar recommendations. Perhaps I’m partial, but I found that the ADA guidelines place higher priority on individualization and collaboration. Plus it’s way more readable! The AACE/TOS guidelines seemed somewhat old school - very prescriptive and unrealistic. This statement was particularly bothersome, “All patients should be instructed on healthy eating and on proper meal planning by qualified health care professionals,” as if once “instructed” clients simply follow in line and adhere. Ah, yes, that’s what my training 30+ years ago reflected, but we’ve learned a lot since then, haven’t we? While this much lengthier paper does address the importance of behavior change and collaboration, these concepts aren’t overarching themes as in the ADA paper.

Please read both sets of guidelines. Then share your thoughts on the eTalk Not One But Two NEW Sets of Nutrition/Healthy Eating Guidelines for Diabetes - Which do you like better? Come on, join in!

As your 2013 comes to an end, are you desperately seeking continuing education credits or just want to re-energize yourself or upgrade your clinical skills? Whichever or all, I’ve got a worthwhile lecture to suggest, Preventing Diabetes by Ronald Tamler, MD, PhD, CDE, Associate Editor at PRESENTdiabetes.com and Assistant Professor of Medicine at Mount Sinai Hospital and Clinical Director of their Diabetes Center. Going forward preventing diabetes is where we need to focus our attention. PRESENTdiabetes.com lectures come with FREE CE through the Academy of Nutrition and Dietetics Commission on Dietetic Registration (CDR) for nutrition professionals. Also all lectures on PRESENTDiabetes.com are approved for CE through the Mt Sinai School of Medicine in New York and the CDR.

Until next time,

References:

1. Evert A, Boucher J, et al. Nutrition therapy recommendations for the management of adults with diabetes. Diabetes Care: e-pub.
2. Wheeler M, Dunbar S: Macronutrient, Food groups, and eating patterns in the management of diabetes. A systematic review of the literature, 2010. Diabetes Care. 2012;35;434-445.