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Updated Consensus Report on Diabetic Nutrition Therapy

Jun 11, 2019
 
Editor: David L. Joffe, BSPharm, CDE, FACA

Author: Adam Chalela, B.S. Doctor of Pharmacy Candidate USF College of Pharmacy

An updated consensus report from the American Diabetes Association has pushed focus towards diabetic nutrition therapy as a viable alternative to classic pharmacotherapy.

Recent studies have led to the publication of a consensus report by the American Diabetes Association (ADA) of optimal nutrition therapy for adults with diabetes or prediabetes. The last consensus report on diabetic nutrition therapy was published in early 2014 and did not target the prediabetic population. As diabetes grows to be one of the most prevalent disease states across the United States of America the ADA has shifted their focus towards overall prevention through utilization of lifestyle modifications, including physical exercise and diet changes.

Diet modifications have had increased recognition over the past years as playing a key role in quality diabetic therapy, as they can assist patients in achieving weight loss goals, maintaining blood glucose values within guideline directed goals, and improving risk factors for developing secondary cardiovascular complications. The ADA utilized the current definition of nutrition therapy as defined by the National Academy of Medicine when outlining specificities for diabetic nutrition therapy. The National Academy of Medicine defines nutrition therapy as “the treatment of a disease or condition through the modification of nutrient or whole-food intake.” When applied to a patient with diabetes, healthcare providers should consider up to date, evidence based information from studies that enrolled populations of patients with diabetes when recommending dietary modifications.

The ADA emphasizes that registered dietician nutritionists should be the primary providers of diabetic nutrition therapy and that primary care providers should refer all patients with type 1 and type 2 diabetes to these specialists for an individualized nutrition plan. Patients over the age of 65 can have Medicare cover the costs of this specialized therapy as it is an entitled benefit. Numerous studies have demonstrated the efficacy of diabetic nutrition therapy as compared to current standard of care medication regimens. Diabetic nutrition therapy as provided by a registered dietician has been shown to improve HbA1C by up to 2% in patients with type 2 diabetes and by up to 1.9% in patients with type 1 diabetes within a 3 to 6 month study period. With this data, it can be deduced that diabetic nutrition therapy can reduce overall pill burden in patients with diabetes which can minimize associated side effects by eliminating the need of medication therapy for glycemic control.

The ADA’s updated 2019 consensus report on diabetic nutrition therapy does not specify any ideal macronutrient breakdown for the average patient with diabetes or prediabetes and found through systematic review that macronutrient intake does not significantly differ between the average person without diabetes and the average person with diabetes. Macronutrient breakdown should be individualized to the patient’s specific goals whether it be overall carbohydrate reduction to reduce blood glucose values or gradual weight loss, and should be the starting point of the registered dietician’s plan. General strategies recommended by the ADA include incorporating more whole foods and non-starchy vegetables into the diet and avoiding refined carbohydrates and processed foods, though the greatest HbA1C lowering effects are observed in diets that reduce overall carbohydrate intake. For even greater outcomes, such as lowering HbA1C and minimizing risk factors for cardiovascular disease, the ADA recommends to incorporate intensive physical activity into diabetic nutrition therapy.

It is important to consider the effects that diabetic nutrition therapy has on specific medication regimens. For example, patients on an intensive insulin regimen may need their total daily dose of insulin reduced once initiated on a nutrition plan that specifically reduces carbohydrate intake with each meal. If left unmanaged, the insulin regimen can pose an increased risk of precipitating hypoglycemic events.

The start of any diabetic treatment plan begins with education, and if it’s possible to achieve desired goals such as weight loss, HbA1c improvements, or cardiovascular disease risk reduction without the need for added medication burden, that avenue should be highly considered.

Practice Pearls

  • All patients with diabetes, whether it be type 1 or type 2, should receive diabetic nutrition therapy.
  • Registered dietician nutritionists are the best providers of diabetic nutrition therapy.
  • Nutrition treatment plans are not homogeneous within the diabetic population and should be tailored to the individual’s specific goals.

Reference: Evert AB, Dennison M, Gardner CD, et al. Nutrition therapy for adults with diabetes or prediabetes: a consensus report. Diabetes Care 2019; 42(5):731-754. DOI: 10.2337/dci19-0014.

Adam Chalela, B.S. Doctor of Pharmacy Candidate USF College of Pharmacy