ADA’s new nutrition guidelines

I read this article about two weeks ago in the online newsletter, that I receive weekly, DiabetesInControl. It’s about the ADA’s new guidelines for nutrition. I’ve reprinted it in its entirety for those of you who want to know the entire text. DiabetesInControl is a free newsletter, you can subscribe here, written largely for diabetes medical professionals containing mostly studies and first findings, but has some interesting news for the layman regarding where research is going and what organizations are doing. What I also enjoy is Dr. Richard Bernstein’s monthly live 60 minute tele-conference where he answers patient’s questions.

What I found particularly interesting about the ADA’s new guidelines is they’re beginning to get on the bandwagon with almost everyone else noting that carbohydrates are the food group that need to be controlled regarding raised blood sugar, and they even come pretty close to admitting that they aren’t counseling people to follow stricter guidelines because people probably can’t do it. You’ll get to that part when below John P. Bantle and his ADA colleagues say, “and changes individuals with diabetes are willing and able to make.” 

Of course I think if your blood sugar or triglycerides or cholesterol isn’t where it should be, and you are not one of the people whom the ADA lumps into the above group, then you should probably apply stricter guidelines to yourself than you’ll read here. What I do find encouraging, on the other hand, is their statement that, “nutrition counseling should be tailored to the personal needs of the individual.” Here, I feel they’re looking at the whole person, their particular medical record, support systems and environment. 

Article: The American Diabetes Association (ADA) has updated its guidelines regarding medical nutrition therapy (MNT), including the use of low-carbohydrate diets to prevent diabetes, manage existing diabetes, and prevent or slow the rate of development of diabetes complications. The revised position statement, which is published in the January issue of Diabetes Care, updates those from 2002 and 2004, presenting evidence-based data published since 2000 and grading of recommendations according to the level of evidence available, based on the ADA evidence-grading system.

John P. Bantle, and colleagues from the ADA write,  “The goal of these recommendations is to make people with diabetes and health care providers aware of beneficial nutrition interventions.”  “This requires the use of the best available scientific evidence while taking into account treatment goals, strategies to attain such goals, and changes individuals with diabetes are willing and able to make. Achieving nutrition-related goals requires a coordinated team effort that includes the person with diabetes and involves him or her in the decision-making process.”

In addition to listing major nutritional recommendations and interventions for diabetes, the updated position statement stresses the importance of monitoring metabolic parameters, including glucose and glycated hemoglobin levels, lipids, blood pressure, body weight, and renal function, during therapy. Such monitoring will help evaluate the need for changes in MNT and thereby optimize outcomes. The authors note that many aspects of MNT require additional research.

Some of the specific recommendations include the following:

Individuals with prediabetes or diabetes should receive individualized MNT, preferably administered by a registered dietitian knowledgeable about the components of diabetes MNT (B).

Nutrition counseling should be tailored to the personal needs of the individual with prediabetes or diabetes and his or her willingness and ability to make changes (E).

Modest weight loss in overweight and obese insulin-resistant individuals has been shown to improve insulin resistance and is therefore recommended for all such individuals who have or are at risk for diabetes (A).

In the short-term (up to 1 year), either low-carbohydrate or low-fat, energy-restricted diets may be effective for weight loss (A).

Patients receiving low-carbohydrate diets should undergo monitoring of lipid profiles, renal function, and protein intake (in patients with nephropathy), and have adjustment of hypoglycemic therapy as needed (E).

Physical activity and behavior modification aid in weight loss and are most helpful in maintaining weight loss (B).

When combined with lifestyle modification, weight loss medications may help achieve a 5% to 10% weight loss and may be considered for overweight and obese individuals with type 2 diabetes (B).

For some patients with type 2 diabetes and a body mass index of 35 kg/m2 or more, bariatric surgery can markedly improve glycemia (B).

Primary prevention for individuals at high risk of developing type 2 diabetes should include structured programs targeting lifestyle changes, with dietary strategies of decreasing energy and dietary fat intakes. Goals should include moderate weight loss (7% body weight), regular physical activity (150 minutes/week) (A), dietary fiber intake of 14 g/1000 kcal, and whole grains comprising half of total grain intake (B).

Intake of low-glycemic index foods that are rich in fiber and other vital nutrients should be encouraged (E), both for the general population and for those with diabetes.

Data do not support recommending alcohol consumption to individuals at risk for diabetes (B).

Secondary prevention, or controlling diabetes, should include a healthy dietary pattern emphasizing carbohydrate from fruits, vegetables, whole grains, legumes, and low-fat milk (B).

A key strategy for achieving glycemic control is to monitor carbohydrate by counting, exchanges, or experienced-based estimation (A). Use of glycemic index and load may be modestly beneficial vs considering only total carbohydrate (B).

Sucrose-containing foods should be limited but can be substituted for other carbohydrates or covered with insulin or other glucose-lowering medications (A). Glucose alcohols and nonnutritive sweeteners are safe within daily US Food and Drug Administration intake levels (A).

Saturated fat should be limited to less than 7% of total energy (A), and trans fat should be minimized (E). In individuals with diabetes, dietary cholesterol should not exceed 200 mg/day (E).

At least 2 servings of fish per week (except for commercially fried fish) are recommended for n-3 polyunsaturated fatty acids (B).

Protein should not be used to treat acute or prevent nighttime hypoglycemia (A). High-protein diets are not recommended for weight loss (E).

If adults with diabetes choose to use alcohol, intake should be restricted to 1 drink per day or less for women and 2 drinks per day or less for men (E) and consumed with food (E).

Practice Pearls

Previous research has suggested that MNT can reduce glycated hemoglobin levels by approximately 1% for patients with type 1 diabetes and 1% to 2% for patients with type 2 diabetes.

The current guidelines do not recommend low-glycemic index or high-protein diets for the routine treatment of patients with diabetes. Moreover, most patients with diabetes should not routinely receive supplements or vitamins.

The ADA has issued practice guidelines for screening, diagnostic, and treatment interventions that are known or believed to improve health outcomes of patients with diabetes. Each recommendation is graded by the ADA as A, B, C, or E to indicate the level of supporting evidence.

Diabetes Care. 2008;31(Suppl 1):S61-S78.

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