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ADA/JDRF Type 1 Diabetes Sourcebook, Excerpt #5: Nutrition, Part 1

Specific Studies

The Dose Adjusted for Normal Eating (DAFNE) trial, conducted in the United Kingdom, evaluated whether a 5-day course teaching adjustments of meal-time insulin based on planned carbohydrate intake could improve both glycemia and quality of life in T1D individuals.3 The insulin regimen was determined first, followed by a consistent meal matched to the timing of insulin action. Individuals were either taught how to determine mealtime bolus insulin doses based on desired carbohydrate intake on a meal-to-meal basis or attended the training 6 months later. In the group receiving the DAFNE training, their A1C levels were improved by 1% (with no significant increase in severe hypoglycemia), they noted positive effects on quality of life and were satisfied with treatment, and they had improved psychological well-being. The results in the treatment group occurred despite an increase in insulin injections (but not in total insulin amount) and an increase in blood glucose monitoring compared with the control subjects.1

A follow-up (mean ~4 years) of the original subjects showed a mean A1C improvement of 0.4% from baseline, remaining significant but less than the 12-month levels. Quality of life improvements were well maintained over ~4 years.4 Another follow-up report examined changes in food and eating practices in the DAFNE trial participants after changing to flexible, intensive insulin therapy. Investigators were concerned that T1D individuals, if given the option to adjust insulin doses based on carbohydrate intake, would overeat or select unhealthy food choices. These concerns were unfounded, as individuals using flexible, intensive insulin therapy did not overeat or choose unhealthy options. Instead, many of the subjects reported making few dietary changes and, in some cases, reported being more rigid in their dietary habits.1,5

A German group reported a lower A1C level (1.5%) 1 year after a 5-day intensive training course. Trained dietitians and nurse educators taught matching insulin doses to dietary choices while maintaining blood glucose levels near normal.6 Improvements lasted 3 years without increasing the risk of hypoglycemia.7 In Australia, dietitians and doctors teaching carbohydrate counting and insulin dose adjustment to T1D or type 2 diabetes (T2D) patients also revealed good results. Participants reported an A1C drop from 8.7% to 8.1% at 12 months.1,8

The Diabetes Control and Complications Trial (DCCT) examined the role of nutrition in achieving glycemic control and found four behaviors associated with a clinically significant reduction in A1C (0.9%): adherence to the prescribed meal and snack plan, adjusting insulin dose in response to meal size, prompt treatment of hyperglycemia, and avoiding overtreatment of hypoglycemia.1,9

MNT AND INSULIN MANAGEMENT

Food plans must be individualized to meet food preferences, eating schedules, physical activity patterns, and cultural influences. Education on the basic diabetes nutrition concepts should begin promptly after diagnosis and be reviewed regularly to encourage adherence. Basic concepts of a food plan should be taught to young children in a developmentally appropriate manner, with specific details given to parents, other family members, and caretakers. Older children and adolescents are often capable of understanding the basics of a meal plan but require parental support and guidance for adherence.10

Based on DCCT results, ADA recommends intensive insulin therapy for all T1D patients, using basal and bolus insulin to reproduce or mimic normal physiological insulin secretion: 1) using multiple-dose insulin injections or insulin pump therapy; 2) matching prandial I:C intake, premeal blood glucose, and anticipated activity; and 3) using insulin analogs, especially if hypoglycemia is a concern.11 The basal and prandial insulin should closely approximate physiologic insulin patterns.12

Insulin therapy should be tailored to the individual’s usual eating and physical activity pattern, with insulin doses adjusted according to the carbohydrate content of meals and snacks. For planned exercise, insulin doses can be adjusted; for unplanned exercise, extra carbohydrates may be needed.12,13

Achieving nutrition-related goals requires a well-coordinated team effort that involves the patient in the decision-making process. The complex nutrition issues require a registered dietitian (RD) knowledgeable in T1D and skilled in implementing nutrition therapy to lead nutrition management.11 However, all team members, including physicians and nurses, should be knowledgeable about nutrition therapy and support its implementation.12,13

The Academy of Nutrition and Dietetics (Acad Nutr Diet) Evidence-based Nutrition Practice Guidelines (EBNPG) state: “MNT plays a crucial role in managing diabetes and reducing the potential complications related to poor glycemic, lipid, and blood pressure control.”14,15 Carbohydrate intake and available insulin primarily determine postprandial glucose levels. Therefore, insulin doses must be adjusted to match carbohydrate intake for those who take mealtime (prandial) insulin or are on CSII. Comprehensive nutrition education and counseling should teach how to interpret blood glucose monitoring patterns and nutrition-related medication management. People using flexible insulin dosing should understand the relationship and coordination of their basal-bolus insulin plan (insulin action) with the blood glucose-raising effect of carbohydrate intake. T1D patients on fixed insulin doses should eat consistent meals and snacks at similar times each day that contain the same amount of carbohydrates, since carbohydrate consistency has shown improved glycemic control.12,13,15

Frequency of MNT

It is recommended that an initial series of three to four encounters with an RD lasting from 45 to 90 min begin at the diagnosis for diabetes or at first referral to an RD for MNT and should be completed within 3 to 6 months.14,15 The RD should determine whether additional MNT encounters are needed and, if so, provide for continued care.14,15 At least one follow-up encounter is recommended annually to reinforce lifestyle changes and to evaluate and monitor outcomes that indicate the need for changes in MNT or medication(s).14,15 Researchers found in the DAFNE program that nutrition support at 6 months was crucial for continued motivation in following an I:C plan.16

REFERENCES
  1. Pastors JG, Franz MJ: Effectiveness of medical nutrition therapy in diabetes. In American Diabetes Association Guide to Nutrition Therapy for Diabetes. 2nd ed. Franz MJ, Evert AB, Eds. Alexandria, VA, American Diabetes Association, 2012, p. 1–18
  2. American Diabetes Association. Clinical Practice Recommendations 2012. Diabetes Care 35 (Suppl. 1):S1–S110, 2012
  3. DAFNE Study Group: Training in flexible, intensive insulin management to enable dietary freedom in people with type 1 diabetes: Dose Adjustment for Normal Eating (DAFNE) randomised controlled trial. BMJ 325:746, 2002
  4. Speight J, Amiel SA, Bradley C, Heller S, Oliver L, Roberts S, Rogers H, Taylor C, Thompson G: Long-term biomedical and psychosocial outcomes following DAFNE (Dose Adjustment For Normal Eating) structured education to promote intensive insulin therapy in adults with sub-optimally controlled type 1 diabetes. Diabetes Res Clin Pract 89:22–29, 2010. Epub 18 April 2010
  5. Lawton J, Rankin D, Cooke DD, Clark M, Elliot J, Heller S: UK NIHR DAFNE Study Group: Dose Adjustment for Normal Eating: a qualitative longitudinal exploration of the food and eating practices of type 1 diabetes patients converted to flexible intensive insulin therapy in the UK. Diabetes Res Clin Pract 91:87–93, 2011. Epub 3 December 2010
  6. Pieber TR, Brunner GA, Schnedl WJ, Schattenberg S, Kaufmann P, Krejs GJ: Evaluation of a structured outpatient group education program for intensive insulin therapy. Diabetes Care 18:625–630, 1995
  7. Sämann A, Mühlhauser I, Bender R, Kloos Ch, Müller UA: Glycaemic control and severe hypoglycaemia following training in flexible, intensive insulin therapy to enable dietary freedom in people with type 1 diabetes: a prospective implementation study. Diabetologia 48:1965–1970, 2005. Epub 18 August 2005
  8. Lowe J, Linjawi S, Mensch M, James K, Attia J: Flexible eating and flexible insulin dosing in patients with diabetes: results of an intensive self-manage-ment course. Diabetes Res Clin Pract 80:439–443, 2008. Epub 18 March 2008
  9. Delahanty LM, Halford BN: The role of diet behaviors in achieving improved glycemic control in intensively treated patients in the Diabetes Control and Complications Trial. Diabetes Care 16:1453–1458, 1993
  10. Spiegel G: Nutrition therapy for youth with diabetes. In American Diabetes Association Guide to Nutrition Therapy for Diabetes. 2nd ed. Franz MJ, Evert AB, Eds. Alexandria, VA, American Diabetes Association, 2012, p. 143–168
  11. American Diabetes Association: Standards of medical care in diabetes—2012. Diabetes Care 35 (Suppl. 1):S11–S63, 2012; doi:10.2337/dc12-s011
  12. Evert AB: Nutrition therapy for adults with type 1 and insulin-requiring type 2 diabetes. In American Diabetes Association Guide to Nutrition Therapy for Diabetes. 2nd ed. Franz MJ, Evert AB, Eds. Alexandria, VA, American Diabetes Association, 2012, p. 95–116
  13. American Diabetes Association: Nutrition recommendations and interventions for diabetes. Diabetes Care 31 (Suppl. 1):S61–S78, 2008; doi: 10.2337/ dc08-S061
  14. Franz MJ, Powers MA, Leontos C, Holzmeister LA, Kulkarni K, Monk A, Wedel N, Gradwell E: The evidence for medical nutrition therapy for type 1 and type 2 diabetes in adults. J Am Diet Assoc 110:1852–1889, 2010
  15. Academy of Nutrition and Dietetics: Diabetes Mellitus Type 1 & 2 Evidence-Based Nutrition Practice Guideline, 2008. Available at http://andevidencelibrary.com/topic.cfm?cat=3252. Accessed 30 October 2012
  16. Casey D, Murphy K, Lawton J, White FF, Dineen S: A longitudinal qualita-tive study examining the factors impacting on the ability of persons with T1DM to assimilate the Dose Adjustment for Normal Eating (DAFNE) principles into daily living and how these factors change over time. BMC Public Health 11:672, 2011

Used with permission by the American Diabetes Association. Copyright © 2013 American Diabetes Association.

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