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ADA/JDRF Type 1 Diabetes Sourcebook, Excerpt #6: Nutrition, Part 2

YOUNG ADULTS AND OLDER

A similar approach to MNT is used with those older than the pediatric patient: individualized food plans based on nutritional, physical and medical needs, food preferences, schedule, access to food, and ability to learn and follow a food plan as well as ability to adjust insulin based on food intake. People who are now living alone, either as a young adult or older individual, may be unfamiliar with purchasing and preparing food and may require some of these basic skills in order to appropriately follow a food plan.

For older individuals with T1D, there are unique nutritional considerations yet there are few studies specifically addressing this age group. Those with long- standing disease may have gastrointestinal complications and alterations in taste that create nutritional challenges. Additionally, dental issues can make it difficult to eat normally, and thus alterations in food choices may be required. Medications that cause gastrointestinal side effects in a patient should be reduced or avoided. Other comorbid conditions such as hypertension, dyslipidemia, and renal insufficiency may require dietary modifications such as low sodium, lower cholesterol, and lower potassium diets, respectively.

It is remarkable how changes due to aging may affect one’s ability to eat nutritiously and enjoy food. For example, it is estimated that at age 70 years people have 70% fewer taste buds than at age 30 years and this may lead older individuals to increase their use of salt and sugar to improve taste satisfaction.25 Loss of smell, vision, hearing, and touch additionally affect food choices.25 When gastrointestinal function is compromised, a review of medications and food intake should be taken. Constipation can be alleviated, in some, with a liberal fluid intake and adequate dietary fiber. 25 Consuming foods labeled sugar free yet containing sugar alcohols may cause gastrointestinal distress. These should be decreased or eliminated, yet replacement foods should be discussed so appropriate substitutions are recommended.

Hospitalization rates increase in older individuals and weight loss can occur from both acute and chronic illness. Thus, it is important to help older patients achieve an appropriate balance: a healthy and nutritious diet designed to maintain a healthy weight with their food preferences and habits formed over a lifetime. Periodic nutritional reassessment of weight and burden of illness as well as changing functional status and ability to obtain healthy food should be undertaken.

Physical activity is strongly encouraged for the elderly population; however, providers must take the patient’s overall health into consideration. (See chapters 11 and 18.)

MACRONUTRIENT CONSIDERATIONS

Rigid approaches to T1D food planning are no longer used. Most RDs aim to normalize the food plan to increase the overall acceptance of healthy food choices. This allows individuals to monitor carbohydrate intake using carbohydrate counting. Blood glucose monitoring helps assess the I:C ratio. According to the ADA 2008 nutrition position statement, it is unlikely that an optimal mix of macronutrients for the diabetic diet exists.13 The dietary reference intakes (DRIs) of the Institute of Medicine (IOM) for an adult healthy eating pattern may be helpful.26 The DRI acceptable macronutrient distribution ranges are 45–65% (carbohydrate), 10–35% (protein), 20–35% (fat), and of total energy (see Table 10.2). The IOM also states that regardless of the macronutrient distribution, total energy intake must be appropriate for weight management. The macronutrient mix should be adjusted to meet the metabolic goals and individual preferences of the patient with diabetes.11,27

A 2012 ADA systematic review of the literature on macronutrients, food groups, and eating patterns in diabetes management concluded that different macronutrient distributions may lead to improvement in glycemic or cardiovascular disease (CVD) risk factors, but different approaches to medical nutrition therapy and eating patterns may equally be as effective.28 RDs should encourage T1D patients to consume macronutrients based on DRIs, since there is insufficient evidence supporting ideal percentages of dietary macronutrients.14,15,27

The Dietary Guidelines for Americans, 2010, includes healthy food options that accommodate cultural, ethnic, traditional, and personal preferences and consider food costs and availability. Although healthy eating patterns widely vary, key elements exist: generous vegetables and fruits, focusing on whole grains, various protein foods in moderation, limited amounts of foods high in added sugars, and more oils than solid fats. The benefits of healthy eating patterns are seen in the Dietary Approaches to Stop Hypertension (DASH), a Mediterranean-style eating pattern, and vegetarianism.27,29

To be continued next week.
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) randomized 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 interven-tions 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
  17. Centers for Disease Control and Prevention: Growth Charts, 2010. Avail-able at http://www.cdc.gov/growthcharts. Accessed 30 October 2012
  18. Silverstein J, Klingensmith G, Copeland K, Plotnick L, Kaufman F, Laffel L, Deeb L, Grey M, Anderson B, Holzmeister LA, Clark N: American Dia-betes Association: Care of children and adolescents with type 1 diabetes: a statement of the American Diabetes Association. Diabetes Care 28:186–212, 2005
  19. Dietary Guidelines Advisory Committee: Report of the Dietary Guide-lines Advisory Committee on the Dietary Guidelines for Americans, 2010, to the Secretary of Agriculture and the Secretary of Health and Human Services. Washington, DC, U.S. Department of Agriculture, Agricultural Research Service, 2010
  20. Helgeson VS, Viccaro L, Becker D, Escobar O, Siminerio L: Diet of ado-lescents with and without diabetes: trading candy for potato chips? Diabetes Care 29:982–987, 2006
  21. Mayer-Davis EJ, Nichols M, Liese AD, Bell RA, Dabelea DM, Johansen JM, Pihoker C, Rodriguez BL, Thomas J, Williams D: SEARCH for Dia-betes in Youth Study Group: Dietary intake among youth with diabetes: the SEARCH for Diabetes in Youth Study. J Am Diet Assoc 106:689–697, 2006
  22. Patton SR, Dolan LM, Powers SW: Dietary adherence and associated gly-cemic control in families of young children with type 1 diabetes. J Am Diet Assoc 107:46–52, 2007
  23. Overby NC, Flaaten V, Veierød MB, Bergstad I, Margeirsdottir HD, Dahl- Jørgensen K, Andersen LF: Children and adolescents with type 1 diabetes eat a more atherosclerosis-prone diet than healthy control subjects. Diabetologia 50:307–316, 2007. Epub 29 November 2006
  24. Overby NC, Margeirsdottir HD, Brunborg C, Andersen LF, Dahl-Jør-gensen K: The influence of dietary intake and meal pattern on blood glu-cose control in children and adolescents using intensive insulin treatment. Diabetologia 50:2044–2051, 2007. Epub 9 August 2007
  25. McLaughlin S: Considerations in caring for older persons with diabetes. In Handbook of Diabetes Medical Nutrition Therapy. Powers MA, Ed. Gaithers-burg, MD, Aspen Publishers, Inc., 1996, p. 527–546
  26. Institute of Medicine: Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids. Washington, DC, National Academies Press, 2002
  27. Franz MJ: Macronutrients and nutrition therapy for 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. 19–40
  28. Wheeler ML, Dunbar SA, Jaacks LM, Karmally W, Mayer-Davis EJ, Wylie- Rosett J, Yancy WS Jr: Macronutrients, food groups, and eating patterns in the management of diabetes: a systematic review of the literature, 2010. Diabetes Care 35:434–445, 2012
  29. U.S. Department of Agriculture, U.S. Department of Health and Human Services: Dietary Guidelines for Americans, 2010. 7th ed. Washington, DC, U.S. Government Printing Office, 2010

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

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