Academy of Nutrition and Dietetics Nutrition Practice Guideline for Type 1 and Type 2 Diabetes in Adults: Nutrition Intervention Evidence Reviews and Recommendations

More sugar? No, thank you! The elusive nature of low carbohydrate diets

In the past decades, dietary guidelines focused on reducing saturated fat as the primary strategy for cardiovascular disease prevention, neglecting the many other potential effects of diet on health, in particular the harmful effects of sugar. A greater intake of soft drinks (sugar-sweetened beverages), for example, is associated with a 44% increased prevalence of metabolic syndrome, a higher risk of obesity, and a 26% increased risk of developing diabetes mellitus. Carbohydrates comprise around 55% of the typical western diet, ranging from 200 to 350 g/day in relation to a person's overall caloric intake. For long-term weight gain, food rich in refined grains, starches, and sugar appear to be major culprits. Low-carbohydrate diets restrict daily carbohydrates between 20 and 50 g, as in clinical ketogenic diets. The results of controlled trials show that people on ketogenic diets (a diet with no more than 50 g carbohydrates/day) tend to lose more weight than people on low-fat diets. Moreover, there is no good evidence for recommending low-fat diets, as low-carbohydrate diets lead to significantly greater weight loss (1.15 kg) than did low-fat interventions. However, the magnitude of such a benefit is small. As the quality of ingested carbohydrates seems more important than the quantity for health outcomes, people with metabolic disorders should avoid or substantially reduce low-fiber, rapidly digested, refined grains, starches, and added sugars. So, the consumption of the right carbohydrates (high-fiber, slowly digested, and whole grains), in a moderately lower amount (between 40 and 50% of daily energy content), is compatible with a state of good health and may represent a scientifically-based and palatable choice for people with metabolic disorders.

Global status of diabetes prevention and prospects for action: A consensus statement

Primary prevention of type 2 diabetes (T2D) should be achievable through the implementation of early and sustainable measures. Several randomized control studies that found success in preventing the progression to T2D in high-risk populations have identified early and intensive intervention based on an individualized prevention model as the key factor for participant benefit. The global prevalence of both overweight and obesity has now been widely recognized as the major epidemic of the 21st century. Obesity is a major risk factor for the progression from normal glucose tolerance to prediabetes and then to T2D. However, not all obese individuals will develop prediabetes or progress to diabetes. Intensive, multicomponent behavioural interventions for overweight and obese adults can lead to weight loss. Diabetes medications, including metformin, GLP-1 agonists, glitazones, and acarbose, can be considered for selected high-risk patients with prediabetes when lifestyle-based programmes are proven unsuccessful. Nutrition education is the cornerstone of a healthy lifestyle. Also, physical activity is an integral part of the prediabetes management plan and one of the main pillars in the prevention of diabetes. Mobile phones, used extensively worldwide, can facilitate communication between health professionals and the general population, and have been shown to be helpful in the prevention of T2D. Universal screening is needed. Noninvasive risk scores should be used in all countries, but they should be locally validated in all ethnic populations focusing on cultural differences around the world. Lifestyle interventions reduce the progression to prediabetes and diabetes. Nevertheless, many questions still need to be answered.

Diet quality is inversely associated with obesity in Chinese adults with type 2 diabetes

Background

Diet quality has been linked to obesity, but this relationship remains unclear in individuals with type 2 diabetes (T2D). The aim of this study is to examine the association between diet quality and obesity in Chinese adults with T2D.

Methods

Between April and November 2016, a total of 211 Chinese T2D adults who underwent assessment of diabetes-related treatment goals and metabolic control were recruited into two groups based on their body mass index (BMI): obese group (BMI ≥30 kg/m²) and non-obese group (BMI = 18.5–24.9 kg/m²). Diet quality indices including Alternate Healthy Eating Index-2010 (AHEI-2010), Diet Quality Index-International (DQI-I), and Dietary Approach to Stop Hypertension (DASH) score, were derived from a validated food frequency questionnaire.

Results

Obese T2D patients had significantly lower AHEI-2010 (P < 0.001), DQI-I (P < 0.001), and DASH total scores (P = 0.044) than their non-obese counterparts, independent of age and sex. They also had higher total energy (P < 0.001), protein percentage of energy (P = 0.023), and meat, poultry and organ meat (P < 0.001), but lower vegetable (P = 0.014) intakes. Our multivariate logistic regression analyses demonstrated that the AHEI-2010, but not DQI-I and DASH, total score had an inverse association with obesity, independent of sociodemographics, anti-diabetic medication use, physical activity level and total energy intake (odds ratio [OR] per standard deviation (1-SD) increase: 0.95, 95% confidence interval [CI]: 0.91–0.99, P = 0.020). This association remained significant after further adjustment for glycemic control. Inverse associations were also found between obesity and multivariate-adjusted component scores, including AHEI-2010 red/processed meat (OR per 1-SD: 0.71, 95% CI: 0.51–0.99, P = 0.044), DQI-I variety (OR per 1-SD: 0.63, 95% CI: 0.46–0.86, P = 0.004), and DASH red/processed meat (OR per 1-SD: 0.57, 95% CI: 0.38–0.84, P = 0.005).

Conclusions

Better diet quality, as characterized by higher AHEI-2010 scores, was associated with lower odds of obesity in Chinese adults with T2D. Dietary patterns reflecting high consumption of plant-based foods and low consumption of animal-based, high-fat, and processed foods may be imperative to optimize nutritional guidance for obesity management in this population.

Electronic supplementary material

The online version of this article (10.1186/s12937-018-0374-6) contains supplementary material, which is available to authorized users.

Eating patterns and food intake of persons with type 1 diabetes within the T1D exchange

AIMS

To identify dietary intake and eating patterns of people with type 1 diabetes from childhood to later adulthood in relation to HbA1c.

METHODS

Trained interviewers conducted 24-hour recalls via phone utilizing a multiple pass approach and administered two nutrition questionnaires; 463 participants (or parents of participants) within the T1D Exchange clinic registry were included. Participants were 5 to 81 years with 80-101 participants in five age groups; 56% were female, and 92% were white, with a median diabetes duration of 11.1 years and a median HbA1c of 7.4% [57 mmol/mol]).

RESULTS

Those with type 1 diabetes consumed less calories from carbohydrates and more from fats and protein than those in the general population, based on the National Health and Nutrition Examination Survey data. Carbohydrate intake was not correlated with HbA1c levels. Increased fiber intake, more eating occasions, higher Healthy Eating Index scores, and higher nutrition knowledge scores were each associated with lower HbA1c levels.

CONCLUSIONS

Food intake, eating patterns and nutrition knowledge are associated with glycemic control across a registry-based cohort of adults and children with type 1 diabetes. Additionally, these data can inform the design of future studies to advance our understanding of nutritional influences on type 1 diabetes self-care and control.

Success of nutrition-therapy interventions in persons with type 2 diabetes: challenges and future directions

A systematic review was conducted by the Academy of Nutrition and Dietetics to determine the evidence for the effectiveness of individualized nutrition therapy provided by a dietitian nutritionist and evidence-based (EB) nutrition-therapy interventions in adults with diabetes. This article briefly reviews the systematic process used and summarizes the effectiveness evidence and intervention recommendations. In persons with type 2 diabetes (T2D), 18 studies met study criteria for the effectiveness question. A 0.3%-2.0% decrease from baseline in glycated hemoglobin was reported at 3 months in 13 study arms, a 0.3%-1.8% decrease at 6 months in 12 study arms, a 0.3%-1.6% decrease at 12 months with ongoing support in six study arms, and a 0.6%-1.8% decrease at >12 months in four study arms. An initial series of encounters with follow-up visits and implementation of a variety of nutrition-therapy interventions, all of which reduced energy intake, were reported. Nutrition therapy also significantly decreased doses or number of glucose-lowering medications used and resulted in improvements in quality of life. Mixed effects on cardiovascular risk factors and body weight were reported. Fourteen questions were identified related to nutrition-therapy interventions. A total of 38 studies met study criteria for the nutrition-intervention questions, from which 30 conclusion statements and 19 nutrition-practice guideline recommendations for T2D were written. Three additional NPG recommendations for T2D were written based on evidence reviewed by the American Diabetes Association. The 22 nutrition-intervention recommendations for T2D are summarized. How to implement nutrition-practice guideline recommendations effectively by health care providers and individuals with T2D remains challenging. Of importance, it is recognized that identifying and integrating EB digital health-technology tools into clinical practice are major challenges for future management of diabetes, self-management education, and support.

Adherence to dietary recommendations in diabetes mellitus: disease acceptance as a potential mediator

BACKGROUND

Adherence by diabetic patients to dietary recommendations is important for effective therapy. Considering patients' expectations in case of diet is significant in this regard. The aim of this paper was to analyze the relationship between selected independent variables (eg, regular blood glucose testing) and patients' adherence to dietary recommendations, bearing in mind that the degree of disease acceptance might play a mediation role.

SUBJECTS AND METHODS

A cross-sectional study was conducted in 91 patients treated for type 2 diabetes mellitus in a public medical facility. Paper-and-pencil interviewing was administered ahead of the planned visit with a diabetes specialist. Two measures were applied in the study: the Acceptance and Action Diabetes Questionnaire and the Patient Diet Adherence in Diabetes Scale. Additionally, data related to sociodemographic characteristics, lifestyle-related factors, and the course of the disease (management, incidence of complications, and dietician's supervision) were also collected. The regression method was used in the analysis, and Cohen's methodology was used to estimate partial mediation. Significance of the mediation effect was assessed by the Goodman test. P-values of <0.05 were considered statistically significant.

RESULTS

Patients' non-adherence to dietary recommendations was related to a low level of disease acceptance (standardized regression coefficient =-0.266; P=0.010). Moreover, failure to perform regular blood glucose testing was associated with a lack of disease acceptance (standardized regression coefficient =-0.455; P=0.000). However, the lack of regular blood glucose testing and low level of acceptance had only partially negative impacts on adherence to dietary recommendations (Goodman mediation test, Z=1.939; P=0.054). This dependence was not seen in patients treated with diet and concomitant oral medicines and/or insulin therapy.

CONCLUSION

Effective dietary education should include activities promoting a more positive attitude toward the disease. This may be obtained by individual counseling, respecting the patient's needs, and focus on regular blood glucose testing.

4. Lifestyle Management: Standards of Medical Care in Diabetes-2018

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.