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Nutrition Therapy for Adults With Diabetes or Prediabetes-ADA Consensus Report

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American Diabetic Association has released its latest Consensus report about Nutrition Therapy for Adults with Diabetes or Prediabetes.

This Consensus Report now includes information on prediabetes, and previous ADA nutrition position statements, the last of which was published in 2014 (4), did not. Unless otherwise noted, the research reviewed was limited to those studies conducted in adults diagnosed with prediabetes, type 1 diabetes, and/or type 2 diabetes. Nutrition therapy for children with diabetes or women with gestational diabetes mellitus is not addressed in this review but is covered in other ADA publications, specifically Standards of Medical Care in Diabetes. Though evidence-based, the recommendations presented are the informed, expert opinions of the authors after consensus was reached through presentation and discussion of the evidence.

The American Diabetes Association’s new consensus report on medical nutrition therapy includes, for the first time, advice on patients with prediabetes. Among the recommendations, published in Diabetes Care:

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  • Patients with prediabetes who are overweight or obese should be referred to an intensive lifestyle intervention with personalized goals, like the Diabetes Prevention Program, and/or to individualized medical nutrition therapy provided by a registered dietitian nutritionist. Evidence supports losing 7%-10% of body weight.
  • Adults with type 1 or 2 diabetes should be referred for individualized medical nutrition therapy both at diagnosis and as health needs change throughout life. Research shows that nutrition therapy can lower hemoglobin A1c at least as well as type 2 diabetes medications.
  • The ideal percentages of calories from carbohydrate, protein, and fat vary in people with diabetes and prediabetes, so “macronutrient distribution should be based on individualized assessment of current eating patterns, preferences, and metabolic goals.”

EFFECTIVENESS OF DIABETES NUTRITION THERAPY

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Consensus recommendations are-

  • Refer adults living with type 1 or type 2 diabetes to individualized, diabetes-focused MNT at diagnosis and as needed throughout the life span and during times of changing health status to achieve treatment goals. Coordinate and align the MNT plan with the overall management strategy, including use of medications, physical activity, etc., on an ongoing basis.
  • Refer adults with diabetes to comprehensive diabetes self-management education and support (DSMES) services according to national standards.
  • Diabetes-focused MNT is provided by a registered dietitian nutritionist/ registered dietitian (RDN), preferably one who has comprehensive knowledge and experience in diabetes care.
  • Refer people with prediabetes and overweight/obesity to an intensive lifestyle intervention program that includes individualized goal-setting components, such as the Diabetes Prevention Program (DPP) and/or to individualized MNT.
  • Diabetes MNT is a covered Medicare benefit and should be adequately reimbursed by insurance and other payers or bundled in evolving value-based care and payment models.
  • DPP-modeled intensive lifestyle interventions and individualized MNT for prediabetes should be covered by third-party payers or bundled in evolving value-based care and payment models.

MACRONUTRIENTS

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Consensus recommendations are-

  • Evidence suggests that there is not an ideal percentage of calories from carbohydrate, protein, and fat for all people with or at risk for diabetes; therefore, macronutrient distribution should be based on individualized assessment of current eating patterns, preferences, and metabolic goals.
  • When counseling people with diabetes, a key strategy to achieve glycemic targets should include an assessment of current dietary intake followed by individualized guidance on self-monitoring carbohydrate intake to optimize meal timing and food choices and to guide medication and physical activity recommendations.
  • People with diabetes and those at risk for diabetes are encouraged to consume at least the amount of dietary fiber recommended for the general public; increasing fiber intake, preferably through food (vegetables, pulses [beans, peas, and lentils], fruits, and whole intact grains) or through dietary supplement, may help in modestly lowering A1C.

EATING PATTERNS

Consensus recommendations are-

  • A variety of eating patterns (combinations of different foods or food groups) are acceptable for the management of diabetes.
  • Until the evidence surrounding comparative benefits of different eating patterns in specific individuals strengthens, health care providers should focus on the key factors that are common among the patterns:
  • Emphasize nonstarchy vegetables.
  • Minimize added sugars and refined grains.
  • Choose whole foods over highly processed foods to the extent possible.
  • Reducing overall carbohydrate intake for individuals with diabetes has demonstrated the most evidence for improving glycemia and may be applied in a variety of eating patterns that meet individual needs and preferences.
  • For select adults with type 2 diabetes not meeting glycemic targets or where reducing antiglycemic medications is a priority, reducing overall carbohydrate
    intake with low- or very low carbohydrate eating plans is a viable approach.

ENERGY BALANCE AND WEIGHT MANAGEMENT

Consensus recommendations are-

  • To support weight loss and improve A1C, CVD risk factors, and quality of life in adults with overweight/ obesity and prediabetes or diabetes, MNT and DSMES services should include an individualized eating plan in a format that results in an energy deficit in combination with enhanced physical activity.
  • For adults with type 2 diabetes who are not taking insulin and who have limited health literacy or numeracy, or who are older and prone to hypoglycemia, a simple and effective approach to glycemia and weight management emphasizing appropriate portion sizes and healthy eating may be considered.
  • In type 2 diabetes, 5% weight loss is recommended to achieve clinical benefit, and the benefits are progressive. The goal for optimal outcomes is 15% or more when needed and can be feasibly and safely accomplished. In prediabetes, the goal is 7–10% for preventing progression to type 2 diabetes.
  • In select individuals with type 2 diabetes, an overall healthy eating plan that results in energy deficit in conjunction with weight loss medications and/or metabolic surgery should be considered to help achieve weight loss and maintenance goals, lower A1C, and reduce CVD risk.
  • In conjunction with lifestyle therapy, medication-assisted weight loss can be considered for people at risk for type 2 diabetes when needed to achieve and sustain 7–10% weight loss.
  • People with prediabetes at a healthy weight should be considered for lifestyle intervention involving both aerobic and resistance exercise and a healthy eating plan such as a Mediterranean-style eating plan.
  • People with diabetes and prediabetes should be screened and evaluated during DSMES and MNT encounters for disordered eating, and nutrition therapy should accommodate these disorders.

SWEETENERS

Consensus recommendations are-

  • Replace sugar-sweetened beverages (SSBs) with water as often as possible.
  • 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.

ALCOHOL CONSUMPTION

Consensus recommendations are-

  • 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.

MICRONUTRIENTS, HERBAL SUPPLEMENTS, AND RISK OF MEDICATION-ASSOCIATED DEFICIENCY

Consensus recommendations are-

  • Without underlying deficiency, the benefits of multivitamins or mineral supplements onglycemia 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.

ROLE OF NUTRITION THERAPY IN THE PREVENTION AND MANAGEMENT OF DIABETES COMPLICATIONS (CVD, DIABETIC KIDNEY DISEASE, AND GASTROPARESIS)

CVD

Consensus recommendations are-

  • 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.
  • People with diabetes and prediabetes are encouraged to consume less than 2,300 mg/day of sodium, thesameamount thatis recommended for the general population.
  • 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.

Diabetic Kidney Disease

Consensus recommendations are-

  • In individuals with diabetes and non–dialysis-dependent diabetic kidney disease (DKD), reducing the amount of dietary protein below the recommended daily allowance (0.8 g/kg body weight/day) does not meaningfully alter glycemic measures, cardiovascular risk measures, or the course of glomerular filtration rate decline and may increase risk for malnutrition

Gastroparesis

Consensus recommendations are-

  • Selection of small-particle-size foods may improve symptoms of diabetesrelated gastroparesis.
  • Correcting hyperglycemia is one strategy for the management of gastroparesis, as acute hyperglycemia delays gastric emptying.
  • Use of CGM and/or insulin pump therapy may aid the dosing and timing of insulin administration in people with type 1 or type 2 diabetes with gastroparesis.

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