New ADA Guidelines Focus on 'Eating Patterns,' not 'Diet'

Miriam E. Tucker

October 18, 2013

New nutritional guidelines from the American Diabetes Association focus on overall eating patterns and patient preference, rather than any particular dietary prescription.

In fact, the authors intentionally avoided using the word "diet," lead author Alison Evert, MS, RD, CDE, coordinator of diabetes education programs at the University of Washington Medical Center, Seattle, told Medscape Medical News.

"Throughout the document, we refer to 'eating plans' or 'eating patterns' rather than 'diet.' We want to work with patients and help them achieve individual health goals. A variety of eating patterns can help, and people are more likely to follow an eating plan that speaks to them," she said

Indeed, the new evidence-based position statement "Nutrition Therapy Recommendations for the Management of Adults With Diabetes," published online October 9 in Diabetes Care, reviews the evidence for several popular eating plans, including Mediterranean style, vegetarian, low fat, low carbohydrate, and Dietary Approaches to Stop Hypertension (DASH), but does not recommend any specific one.

"Personal preferences (eg, tradition, culture, religion, health beliefs and goals, economics) and metabolic goals should be considered when recommending one eating pattern over another," the statement says.

Importantly, early referral to a registered dietician for nutrition therapy is advised as soon as possible following the diabetes diagnosis. "What we know from the research is that when a patient is referred soon after diabetes has been diagnosed, nutrition therapy can be effective. Unfortunately, that referral is often delayed, sometimes for years," Ms. Evert told Medscape Medical News.

"Priority" Section Assists Busy Clinicians

The new statement replaces the ADA's 2008 "Nutritional Recommendations and Interventions for Diabetes." In addition to the section on the eating plans, it includes other new features and recommendations, such as a guide for coordinating food with different types of oral glucose-lowering agents and both fixed-dose and basal-bolus insulin regimens.

The latter is included in a table entitled "Summary of priority topics," a concept that is meant to assist in time-limited clinical scenarios. "The idea is that because nutrition therapy is a core tenet of diabetes management, if a clinician has less than a minute devoted to lifestyle intervention topics, here are some talking points that are evidence-based that clinicians can use with patients," Ms. Evert said.

These include emphasizing portion control as a method for weight loss and maintenance and ensuring that the patient knows which foods contain carbohydrates.

With regard to carbohydrates, the document advises that patients choose nutrient-dense, high-fiber foods as opposed to processed foods with added sodium, fat, and sugars. And for the first time, the guidelines specifically call for the avoidance of sugar-sweetened beverages (SSBs).

As in 2008, this guideline does not recommend specific proportions of daily calories from carbohydrate, fats, and proteins in the diet. Rather, the statement says, "macronutrient distribution should be based on individualized assessment of current eating patterns, preferences, and goals."

Acknowledging the popularity of low-carb and low-glycemic-index eating patterns among many in the diabetes community, Ms. Evert told Medscape Medical News that the committee reviewed as much available evidence as possible in those areas but stopped short of recommending any specific ones. For example, "A lot of the studies on low-carb didn't meet our criteria for inclusion due to factors such as high dropout rates," she observes.

As for other macronutrients, the document advises that foods containing unsaturated fats (liquid oils) be substituted for those higher in trans- or saturated fat and that leaner protein sources and meat alternatives are preferred.

And in a change from 2008, the limit for sodium is given as 2300 mg/day, the same as for the general population. Alternate individualized sodium targets are recommended for patients with both diabetes and hypertension, however.

Previously, the recommendation had been less than 2000 mg/day for all diabetes patients. "The research that we found didn't support a lower sodium recommendation for people with diabetes," Ms. Evert told Medscape Medical News.

The document also advises against the use of any specific vitamin or mineral supplement or herbs for people with diabetes.

Similarly, evidence also doesn't support recommending omega-3 supplements for people with diabetes as a way of preventing or treating cardiovascular disease.

"There's no evidence at this point beyond eating healthy… Without well-designed clinical trials to prove efficacy, the benefit of pharmacological doses of supplements is unknown. Unfortunately, findings from small clinical and animal studies are frequently extrapolated to clinical practice," she noted.

"An Underutilized Therapy"

Ms. Evert told Medscape Medical News she hopes that the new statement will encourage providers to focus more attention on food as a critical element of diabetes management. "Often, nutrition therapy isn't given the priority that it should have… It's a lot easier to write a prescription than to have a dialog with the patient about eating behaviors."

She pointed out that nutrition therapy has been shown to produce cost savings and improve glycemic control. Moreover, "It's often a covered benefit for many patients who have insurance… It's an underutilized therapy."

Ms. Evert has no reported no relevant financial relationships. Disclosures for the coauthors are listed in the article.

Diabetes Care. Published online October 9, 2013. Article

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