ADA Nutrition Position Statement

Educational Objectives

The goal of this program is to improve the management of diabetes. After hearing and assimilating this program, the clinician will better be able to:

1. Identify patients at risk for developing diabetes and refer them to a dietitian or help them make appropriate lifestyle changes.
2. Communicate with patients with newly diagnosed diabetes about their diet and make timely referrals to dietitians.
3. Help patients understand what makes up a healthy diet for people with diabetes.

Summary

Background

In 2013 the ADA published an updated position statement on nutrition: Nutrition Therapy Recommendations for the Management of Adults with Diabetes. The last position statement had been published in 2006. Since then, several studies have demonstrated the effectiveness of medical nutrition therapy. In type 1 diabetes, studies have reported a 0.3% to 1% reduction in A1C when medical nutrition therapy is offered. Studies in type 2 diabetes report 0.5% to 2% reductions in A1C with medical nutrition therapy.

The writing committee for the updated position statement examined the evidence for an ideal macronutrient distribution; they also looked at healthy eating patterns. When considering diet, patients are more likely to think in terms of eating patterns (ie, following a particular diet or eating healthier foods) than trying to figure out the percent of their calories coming from different macronutrients.

Macronutrient distribution

The writing committee found no evidence that any particular macronutrient distribution was the absolute best way to help patients achieve adequate glycemic control or decrease cardiovascular (CV) risk factors. Therefore, they made no recommendations for macronutrient distribution.

Nutritional professionals are encouraged to talk to patients, identify food preferences, and individualize dietary recommendations based on their metabolic goals and preferences.

Healthy eating patterns

The writing committee reviewed evidence on the effect of specific eating patterns (Mediterranean, vegetarian, vegan, low fat, low carbohydrate, and the DASH [Dietary Approaches to Stop Hypertension] diet) on glycemic control and reduction in CV risk factors. They concluded that there was no one preferred eating pattern.

Health care professionals need to have the skills to ask patients the right questions to determine the eating pattern that will work best for them based on their personal preferences, cultural preferences, socioeconomic status, and metabolic goals.

Referral to a dietitian

Once patients have had diabetes for a while they begin to understand that a dietary plan is not as simple as following instructions on a sheet of paper that tells them to eat certain foods and avoid others. They need to meet with a dietitian or other nutrition professional to figure out an eating pattern that will work best for them.

Patients may resist seeing a dietitian because they fear being admonished for what they eat and fear being told what they can’t eat. Physicians can help to change that perception by informing patients that a dietitian will help them to figure out how to live with diabetes, which they will have for the rest of their lives, and to still be able to eat the foods that are important to them.

Cultural differences

More research is needed on translating healthy eating patterns for different cultures. For example, a growing body of evidence suggests that a Mediterranean style of eating (which focuses on fruits and vegetables, limited fish and lean meats, and olive oil and nuts) may have advantages in terms of glycemic control and reduction in CV risk factors. It may be difficult, for example, to recommend this eating pattern to a person who lives on an Indian reservation and has very different traditional eating habits. Research is needed to identify the key parts of the Mediterranean diet that are most important for people to follow and how they can be adapted for other personal and cultural preferences.

Protein recommendations

The protein recommendation for people with diabetes and chronic kidney disease (CKD) has changed over the years. In the past, once patients with CKD reached a certain threshold, protein restriction often was recommended.

Several newer randomized, controlled trials show that restricting protein in patients with diabetes and CKD does not have an effect on glomerular filtration rate or urinary albumin excretion rate.

Clinical Pearl The current recommendation is that patients with chronic kidney disease should not be on a protein-restricted diet.

Refractory patients

Working with patients who resist making any changes is challenging. The first step is to ask them what is really hard about healthy eating (ie, what do you really hate about the diabetes diet?). It can sometimes be useful to help them understand the science behind whatever is hard for them to do. Additionally, some patients have erroneous ideas about what they should be doing. Health care professionals should update their education, because they may actually be able to eat some of their favorite foods they thought were forbidden.

The patient’s perspective

Health care professionals should find out what is important to patients and determine what is difficult for them when it comes to healthy eating and diabetes. Making an effort to understand these aspects of the patient’s life will have the biggest impact on helping them to achieve behavior change.

Readings

Boule NG et al: Effects of exercise on glycemic control and body mass in type 2 diabetes mellitus: a meta-analysis of controlled clinical trials. JAMA 2001;286:1218-27; Church et al: Effects of aerobic and resistance training on hemoglobin A1c levels in patients with type 2 diabetes: a randomized controlled trial. JAMA 2010;304:2253-62; Colberg SR et al: Exercise and type 2 diabetes: the American College of Sports Medicine and the American Diabetes Association: joint position statement executive summary. Diabetes Care 2010;33:2692-6; Evert AB et al: Nutrition therapy recommendations for the management of adults with diabetes. Diabetes Care 2013;36:3821-42; Gagnon C et al: A cost-effective moderate-intensity interdisciplinary weight-management programme for individuals with prediabetes. Diabetes Metab 2011;37:410-8; Garber CE et al: American College of Sports Medicine position stand. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise. Med Sci Sports Exerc 2011;43:1334-59; Kanade RV et al: Walking performance in people with diabetic neuropathy: benefits and threats. Diabetologia 2006;49:1747-54; Katula JA et al: One-year results of a community-based translation of the Diabetes Prevention Program: Healthy-Living Partnerships to Prevent Diabetes (HELP PD) Project. Diabetes Care 2011;34:1451-7; Lindstrom J et al: The Finnish Diabetes Prevention Study (DPS): Lifestyle intervention and 3-year results on diet and physical activity. Diabetes Care 2003;26:3230-6; Morrison S et al: Balance training reduces falls risk in older individuals with type 2 diabetes. Diabetes Care 2010;33:748-50; Munakata M et al: Repeated counselling improves the antidiabetic effects of limited individualized lifestyle guidance in metabolic syndrome: J-STOP-METS final results. Hypertens Res 2011;34:612-6; Nelson ME et al: Physical activity and public health in older adults: recommendation from the American College of Sports Medicine and the American Heart Association. Med Sci Sports Exerc 2007;39:1435-45; Orozco LJ et al: Exercise or exercise and diet for preventing type 2 diabetes mellitus. Cochrane Database Syst Rev 2008:CD003054; Wheeler ML et al: Macronutrients, food groups, and eating patterns in the management of diabetes: a systematic review of the literature, 2010. Diabetes Care 2012;35:434-45.

Disclosures

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest.  For this program, the following was disclosed: Dr. Anderson reported relationships with Amylin Pharmaceuticals (B), Daichii Sankyo Company. (B), Eli Lilly and Company (B), Novo Nordisk (B), and sanofi-aventis US (A). Dr. Urbanski  reported relationships with Janssen Pharmaceuticals (A). The members of the planning committee reported nothing to disclose.

A=Advisory panel B=Speakers bureau C=Consultant G=Grant or other research support

Acknowledgements

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

DI050702

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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