Hot Off the Press: Nutrition Therapy Recommendations for Adults with Diabetes

By Alison Evert, MS , RD, CDE

After receiving a diagnosis of diabetes, your health care provider (HCP) is likely to suggest lifestyle changes such as eating a “healthful” diet and avoiding sugar-sweetened beverages. In many cases, an additional goal of losing weight also will be encouraged. Along with physical activity and taking diabetes medicine (as needed/prescribed), following a healthy eating plan is an important component of the overall treatment plan for the management of diabetes. Why do HCPs make these recommendations, and how do they stay up-to-date on the best treatment approaches for the management of diabetes? Many HCPs turn to professional organizations such as the American Association of Clinical Endocrinologists (AACE) or the American Diabetes Association (ADA) for evidence-based recommendations to help guide their practice. Recently the ADA published Nutrition Therapy Recommendations for the Management of Adults with Diabetes. To produce the document, the organization assembled a group of nutrition experts and other diabetes health care team members (registered nurse, nurse practitioner, physician, pharmacist and nutrition researcher) which thoroughly reviewed the research conducted over the last decade about what nutrition therapy interventions are effective in people with diabetes. The team of experts made the decision to use the term “eating plan” in the report rather than “diet,” which has historically been negatively associated with restriction. The team also determined that there is no “one-size fits all” way to eat. Since people eat food and not single nutrients such as carbohydrates, protein and fat, the report includes a new eating patterns section. Eating patterns can be defined as combinations of different foods or food groups. Many different types of eating patterns can be effective for achieving personal health goals for people with diabetes. For example, eating patterns that have been studied in people with diabetes include: Mediterranean-style, vegetarian or vegan, low-carbohydrate, low-fat, glycemic index, and Dietary Approaches to Stop Hypertension (DASH). The freedom for a patient to select from a variety of patterns, given individualized health goals and preferences, should be supported by the health care team. The paper also included several goals for nutrition therapy in people with diabetes. One of the primary goals is the development of an individualized eating plan that can help to achieve personal targets for blood glucose, blood pressure, cholesterol and triglyceride levels while also taking into consideration personal and cultural preferences, access to healthy food choices, and willingness and ability to make changes in food and beverage choices. It can be developed in collaboration with a registered dietitian or through participation in a diabetes self-management group education class. It has also been determined that ongoing follow-up with a diabetes health care professional is critical for success for a disease that is largely self-managed by the person with diabetes. Many people are instructed to “count carbohydrates” after receiving a diagnosis of diabetes, since the amount of carbohydrates that are eaten has a direct effect on the blood glucose (sugar) level in people with diabetes after eating. However, the quality of the carbohydrate eaten is an important factor as well. In general, carbohydrate intake from whole grains, fruits, vegetables, legumes and milk should be encouraged over food sources with added sugars, sodium and fat. The effectiveness of the carbohydrate counting meal planning approach has been studied since the 1990s, and studies show that people with type 1 diabetes can lower their A1C level -- an index of a person’s average blood glucose for the previous three or four months -- by 0.3 percent to one percent using this meal-planning approach. People with type 2 diabetes can also achieve A1C reductions that range from 0.5 to 2 percent as aresult of nutrition therapy education provided either in a one-on-one session with a registered dietitian or by attending a group diabetes education class. In addition to carbohydrate counting, effective nutrition therapy strategies for people with type 2 diabetes include simple and easy approaches such as education on portion control and healthful food choices. Modest weight loss has been shown to improve glucose and cholesterol levels and blood pressure, especially those with newly diagnosed type 2 diabetes. To achieve modest weight loss, intensive lifestyle interventions (physical activity, counseling about nutrition and behavior change) and ongoing support are recommended. Regarding use of supplements for the treatment of diabetes, the report indicated there is a lack of evidence to support use of vitamin and mineral supplements, herbal products or cinnamon to manage diabetes at this time. However, it is important to report the use of these products to your HCP. Unfortunately, due to the progressive nature of type 2 diabetes, physical activity and nutrition therapy alone may not be effective in maintaining desirable blood glucose control. Over time, many individuals need to add diabetes medicine to their treatment plan. However, after diabetes medicine is started, nutrition therapy continues to be a key part of self-managing type 2 diabetes. To assist, the ADA report contained a summary section on priorities for the nutritional management of diabetes. To eat well, it recommended nutrient-dense foods (fiberrich with a lot of nutrients but relatively few calories in appropriate portion sizes). The list of choices includes:
  • Grains, especially whole grains
  • Fruits and vegetables – fresh, frozen or canned with “lite sodium”
  • Fat-free or low-fat milk or dairy-like products
  • Leaner protein sources or meat alternatives such as beans, lentils and unsalted nuts
  • Unsaturated substitutes (liquid fats such as olive, canola, corn, safflower oil) for foods higher in saturated (solid) fats or trans fats as much as possible
Additionally, the report recommends avoiding sugar sweetened beverages such as regular soda pop, sports drinks and vitamin-like water; limiting salt (sodium) ingestion to 2,300 mg per day; and, for those adults with diabetes who choose to drink alcohol, doing so in moderation (one drink per day or less for women and to two drinks for men). Bottom line, the effective management of diabetes includes an individualized eating plan and developed in collaboration with your health care team along with ongoing support.

Alison Evert currently coordinates the diabetes education programs at the University of Washington Medical Center, Diabetes Care Center., Seattle, Washington. She served as co-chair of the ADA Position Statement: Nutrition Therapy recommendations for the Management of Adults with Diabetes committee and writing group.