Nutrition Therapy Recommendations for the Management of ...

Nutrition Therapy Recommendations for the Management of ...

Nutrition Therapy Recommendations for the Management of Adults With Diabetes Position Statement American Diabetes Association 2013 Evert AB et al. Nutrition Therapy Recommendations for the Management of Adults With Diabetes. Diabetes Care Publish Ahead of Print, DOI: 10.2337/dc13-2042.

Diabetes Care Publish Ahead of Print, published online October 9, 2013 Preamble The common co-existence of hyperlipidemia and hypertension in people with diabetes requires monitoring of metabolic parameters (e.g. glucose, lipids, blood pressure, body weight, renal function) to ensure successful health outcomes Nutrition therapy that includes the development of an eating pattern designed to lower glucose, blood pressure and alter lipid profiles is important in the management of diabetes as well as lowering the risk of cardiovascular disease (CVD),

coronary heart disease and stroke Evert AB et al. Nutrition Therapy Recommendations for the Management of Adults Preamble A healthful eating pattern, regular physical activity and often pharmacotherapy are key components of diabetes management After pharmacotherapy is initiated, nutrition therapy continues to be an important component of the overall treatment plan For many individuals with diabetes, the most challenging part of the treatment plan is determining what to eat

It is the position of the American Diabetes Association (ADA) that there is not a one-size-fits-all eating pattern for individuals with diabetes Evert AB et al. Nutrition Therapy Recommendations for the Management of Adults Preamble This position statement replaces previous position statements, the last of which was published in 2008 Research reviewed was limited to those studies conducted in adults diagnosed with type 1 or type 2 diabetes

Nutrition therapy for the prevention of type 2 diabetes, management of diabetes complications and gestational diabetes mellitus is not addressed in this review Evert AB et al. Nutrition Therapy Recommendations for the Management of Adults Goals of nutrition therapy in adults with diabetes To promote and support healthful eating patterns, emphasizing a variety of nutrient dense foods in appropriate portion sizes, in order to improve overall

health and specifically to: Attain individualized glycemic, blood pressure and lipid goals as follows:* A1C < 7% Blood pressure < 140/80 mm Hg LDL cholesterol < 100 mg/dL; triglycerides < 150 mg/dL; HDL cholesterol > 40 mg/dL for men; HDL cholesterol > 50 mg/dL for women Achieve and maintain body weight goals Delay or prevent complications of diabetes

*A1C, blood pressure and cholesterol goals may need to be adjusted for the individual based on age, duration of diabetes, health history, and other present health conditions. A1C Glycosylated hemoglobin, HDL High density lipoproteinEvert AB et al. Nutrition Therapy Recommendations for the Management of Adults Goals of nutrition therapy in adults with diabetes To address individual nutrition needs based on personal and cultural preferences, health literacy and numeracy, access to healthful food choices, willingness and ability to make behavioral changes, as well as barriers to change

To maintain the pleasure of eating by providing positive messages about food choices while limiting food choices only when indicated by scientific evidence To provide the individual with diabetes with practical tools for day-to-day meal planning rather than focusing on individual macronutrients, micronutrients or single foods Evert AB et al. Nutrition Therapy Recommendations for the Management of Adults Diabetes Nutrition Therapy

Patients with diabetes should be referred to a registered dietitian (RD) [or a similarly credentialed nutrition professional if outside of the U.S.] for nutrition therapy at/or soon after diagnosis and for ongoing follow-up Alternatively they may be referred to a comprehensive diabetes self-management education (DSME) program that includes instructions on nutrition therapy Evert AB et al. Nutrition Therapy Recommendations for the Management of Adults

Diabetes Nutrition Therapy Academy of Nutrition and Dietetics Evidence-Based Nutrition Practice Guidelines recommend this structure for the implementation of MN for adults with diabetes MNT - Medical nutrition therapy RD - Registered dietitian Evert AB et al. Nutrition Therapy Recommendations for the

Management of Adults Effectiveness of nutrition therapy Findings from randomized controlled trials and from systematic and Cochrane reviews demonstrate the effectiveness of nutrition therapy for improving glycemic control and various markers of cardiovascular and hypertension risk In the general population, MNT provided by an RD to individuals with an abnormal lipid profile has been shown to reduce daily fat (58%), saturated fat (24%), and energy intake (232710 kcal/day), and lower triglycerides (1131%),

LDL cholesterol (722%), and total cholesterol (721%) levels MNT - Medical nutrition therapy RD - Registered dietitian Evert AB et al. Nutrition Therapy Recommendations for the Management of Adults Effectiveness of nutrition therapy Effective nutrition therapy interventions may be a component of a comprehensive group diabetes education program or an individualized session

Reported A1C reductions are similar or greater than what would be expected with treatment with currently available pharmacologic treatments for diabetes The documented decreases in A1C observed in these studies include: type 1 diabetes - 20.3% to 21% and type 2 diabetes - 20.5% to 22% A1C Glycosylated hemoglobin Evert AB et al. Nutrition Therapy Recommendations for the Management of Adults

Effectiveness of nutrition therapy In interventional studies lasting 12 months or longer and targeting individuals with type 2 diabetes to reduce excess body weight, modest weight losses were achieved ranging from 1.9 kg to 8.4 kg In the Look AHEAD trial, at the end of the study (~ 10 years), the mean weight loss from baseline was 6% in the intervention group and 3.5% in the control group Evert AB et al. Nutrition Therapy Recommendations for the Management of Adults

ADA 2013 evidence - grading system for clinical practice recommendations ADA 2013 evidence - grading system for clinical practice recommendations Nutrition therapy recommendations MNT - Medical nutrition therapy, RD - Registered dietitian, A1C Glycosylated hemoglobin DSME - Diabetes self-management education Evert AB et al. Nutrition Therapy Recommendations for the

Management of Adults Nutrition therapy recommendations Evert AB et al. Nutrition Therapy Recommendations for the Management of Adults Nutrition therapy recommendations * * 14 g fiber/1,000 kcals daily or about 25 g/day for adult women and 38 g/day for adult men

Evert AB et al. Nutrition Therapy Recommendations for the Management of Adults Nutrition therapy recommendations NNSs - Non-nutritive sweeteners, SSBs - Sugar-sweetened beverages Evert AB et al. Nutrition Therapy Recommendations for the Management of Adults Nutrition therapy recommendations GFR Glomerular filtration rate CVD Cardiovascular disease

Evert AB et al. Nutrition Therapy Recommendations for the Management of Adults Nutrition therapy recommendations MUFA Monounsaturated fatty acid , EPA Eicosapentaenoic acid, DHA Docosahexaenoic acid Evert AB et al. Nutrition Therapy Recommendations for the PUFA Polyunsaturated fatty acid Management of Adults Nutrition therapy recommendations

LDL Low density lipoprotein Evert AB et al. Nutrition Therapy Recommendations for the Management of Adults Nutrition therapy recommendations * * Saturated fat < 10% of calories, aiming for < 300 mg dietary cholesterol/day, and limiting trans fat as much as possible Evert AB et al. Nutrition Therapy Recommendations for the

Management of Adults Eating patterns Eating patterns, also called dietary patterns, is a term used to describe combinations of different foods or food groups that characterize relationships between nutrition, health promotion and disease prevention Eating patterns studied among individuals with type 1 or type 2 diabetes were reviewed to evaluate their impact on diabetes nutrition goals (as incorporated in the successive slides)

Evert AB et al. Nutrition Therapy Recommendations for the Management of Adults Reviewed eating patterns Evert AB et al. Nutrition Therapy Recommendations for the Management of Adults Reviewed eating patterns DASH Dietary Approaches to Stop Hypertension

Evert AB et al. Nutrition Therapy Recommendations for the Management of Adults Eating patterns The Mediterranean-style eating pattern, mostly studied in the Mediterranean region, has been observed to improve cardiovascular risk factors (i.e., lipids, blood pressure, triglycerides) in individuals with diabetes and lower combined end points for CVD events and stroke, when supplemented with mixed nuts (including walnuts, almonds, and hazelnuts) or olive oil

Individuals following an energy-restricted Mediterranean-style eating pattern also achieve improvements in glycemic control CVD Cardiovascular disease Evert AB et al. Nutrition Therapy Recommendations for the Management of Adults Eating patterns The low-fat eating pattern is one that has often been encouraged as a strategy to lose weight or to improve cardiovascular health within the U.S

In the Look AHEAD trial, an energy-reduced low-fat eating pattern was encouraged for weight loss, and individuals achieved moderate success However, in a systematic review and in four studies and in a metaanalysis published since the systematic review, lowering total fat intake did not consistently improve glycemic control or CVD risk factors Benefit from a low fat eating pattern appears to be more likely when energy intake is also reduced and weight loss occurs CVD Cardiovascular disease Evert AB et al. Nutrition Therapy Recommendations for the Management of Adults

Clinical priorities for nutrition management A wide range of diabetes meal planning approaches or eating patterns have been shown to be clinically effective (many include a reduced energy intake component) None has an ideal percentage of calories from carbohydrates, protein or fat that is optimal for all people with diabetes Nutrition therapy goals should be developed collaboratively with the individual with diabetes and be based on an assessment of the individuals

current eating patterns, preferences and metabolic goals Evert AB et al. Nutrition Therapy Recommendations for the Management of Adults Clinical priorities for nutrition management Once a thorough assessment is completed, the health care professionals role is to facilitate behavior change and achievement of metabolic goals while meeting the patients preferences, which may include allowing the patient to continue following his/her current eating

pattern If the individual would like to try a different eating pattern, this should also be supported by the health care team Evert AB et al. Nutrition Therapy Recommendations for the Management of Adults Clinical priorities for nutrition management Various behavior change theories and strategies can be used to tailor nutrition interventions to help the client achieve specific health and quality-of-life outcomes

Multiple meal planning approaches and eating patterns can be effective for achieving metabolic goals The meal planning approach or eating pattern should be selected based on the individuals personal and cultural preferences; literacy and numeracy; and readiness, willingness and ability to change Evert AB et al. Nutrition Therapy Recommendations for the Management of Adults Diabetes self-management education/support In addition to diabetes MNT provided by an RD,

diabetes self-management education (DSME) and diabetes self-management support (DSMS) are critical elements of care for all people with diabetes and are necessary to improve outcomes in a disease that is largely self-managed The National Standards for Diabetes SelfManagement Education and Support recognize the importance of nutrition as one of the core curriculum topics taught in comprehensive programs MNT - Medical nutrition therapy RD - Registered dietitian

Evert AB et al. Nutrition Therapy Recommendations for the Management of Adults Summary of key topics for nutrition education SSBs - Sugar-sweetened beverages Evert AB et al. Nutrition Therapy Recommendations for the Management of Adults

Summary of key topics for nutrition education *Treatment of hypoglycemia - current recommendations include the use of glucose tablets or carbohydrate-containing foods or beverages (such as fruit juice, sports drinks, regular soda pop or hard candy) to treat hypoglycemia. A commonly recommended dose of glucose is 1520 g. When blood glucose levels are ~ 5060 mg/dL, treatment with 15 g of glucose can be expected to raise blood glucose levels ~ 50 mg/dL. If self-monitoring of blood glucose and about 1520 min after treatment shows continued hypoglycemia, the treatment should be repeated Evert AB et al. Nutrition Therapy Recommendations for the Management of Adults

Summary of key topics for nutrition education *Treatment of hypoglycemia - current recommendations include the use of glucose tablets or carbohydrate-containing foods or beverages (such as fruit juice, sports drinks, regular soda pop or hard candy) to treat hypoglycemia. A commonly recommended dose of glucose is 1520 g. When blood glucose levels are ~ 5060 mg/dL, treatment with 15 g of glucose can be expected to raise blood glucose levels ~ 50 mg/dL. If self-monitoring of blood glucose and about 1520 min after treatment shows continued hypoglycemia, the treatment should be repeated GLP-1: Glucagon-like peptide-1 Evert AB et al. Nutrition Therapy Recommendations for the

Management of Adults Summary of key topics for nutrition education *Treatment of hypoglycemia - current recommendations include the use of glucose tablets or carbohydrate-containing foods or beverages (such as fruit juice, sports drinks, regular soda pop or hard candy) to treat hypoglycemia. A commonly recommended dose of glucose is 1520 g. When blood glucose levels are ~ 5060 mg/dL, treatment with 15 g of glucose can be expected to raise blood glucose levels ~ 50 mg/dL. If self-monitoring of blood glucose and about 1520 min after treatment shows continued hypoglycemia, the treatment should be repeated Evert AB et al. Nutrition Therapy Recommendations for the

Management of Adults Future research directions Evaluating nutrition evidence is complex given that multiple dietary factors influence glycemic control and CVD risk factors, and the influence of a combination of factors can be substantial Based on a review of the evidence, it is clear that gaps in the literature continue to exist and further research on nutrition and eating patterns is needed in individuals with type 1 and type 2 diabetes CVD Cardiovascular

disease Evert AB et al. Nutrition Therapy Recommendations for the Management of Adults Future research directions Future studies should address The relationships between eating patterns and disease in diverse populations The basis for the beneficial effects of the Mediterraneanstyle eating pattern and approaches to translation of the Mediterranean-style eating pattern into diverse populations

The development of standardized definitions for high and low glycemic index diets and implementation of these definitions in long-term studies to further evaluate Evert AB et al. Nutrition Therapy Recommendations for the Management of Adults Future research directions Future studies should also address The development of standardized definitions for low to moderate carbohydrate diets and determining long-term sustainability Whether NNSs, when used to replace caloric sweeteners,

are useful in reducing caloric and carbohydrate intake The impact of key nutrients on cardiovascular risk, such as saturated fat, cholesterol and sodium in individuals with both type 1 and type 2 diabetes NNSs - Non-nutritive sweeteners, SFA Saturated fatty acids Intake of SFA and its relationship to insulin resistance Evert AB et al. Nutrition Therapy Recommendations for the Management of Adults Future research directions

Given the benefits of both nutrition therapy and MNT for individuals with diabetes, it is also important to study systematic processes within the context of health care delivery that encourage more individuals with diabetes to receive nutrition therapy initially, upon diagnosis, and long term Further research is also needed on the best tools and strategies for educating individuals with diabetes (e.g., the Plate Method) and how to improve adherence to healthful eating patterns MNT - Medical nutrition therapy

among individuals Evert with diabetes AB et al. Nutrition Therapy Recommendations for the Management of Adults Conclusions 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 readiness, willingness and ability to change Evert AB et al. Nutrition Therapy Recommendations for the Management of Adults Conclusions Nutrition interventions should emphasize a variety of minimally processed nutrient dense foods in appropriate portion sizes as part of a healthful eating pattern

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 Evert AB et al. Nutrition Therapy Recommendations for the Management of Adults

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