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ADA issues position statement on standards of medical care
ADA/EASD’s consensus algorithm updated with data on TZDs.
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The American Diabetes Association released a position statement in January outlining standards of medical care that includes recommendations on medical nutrition therapy for the prevention and management of diabetes.
The position statement, “Standards of Medical Care in Diabetes,” indicates that diets restricting carbohydrates or fat calorie intake can be effective for reducing weight for up to one year.
“We have been evaluating the evidence of low-carbohydrate diets and feel that, at this point in time, there is reasonable evidence to indicate that individuals are able to achieve weight loss either on a low-carbohydrate diet or a low-fat, calorie-restricted diet,” Ann Albright, PhD, RD, president, Health Care and Education at the ADA, told Endocrine Today.
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Reducing portions, increasing physical activity and modifying behavior are all important determinants in whether or not a patient will succeed in losing weight and keeping it off, according to Albright.
“Food is a very personal issue. People console with food, they celebrate with food; it is more than just fueling the body,” she said.
“Not everyone is going to want to be on a low-carbohydrate diet because that is not what their food preferences are. Some may find a low-fat diet easier to follow. Talk to your patients to find out their preferences; ongoing support is a big part of weight loss.”
The recommendations counsel that patients with diabetes should carefully monitor their health when following a restrictive weight loss plan. For example, patients who choose to follow a low-carbohydrate diet need to monitor their lipid profile as they replace calories from carbohydrates with fat or protein.
Diets high in protein may worsen kidney problems so dieters should closely monitor their kidney function and consult with a health care professional about adequate amounts of protein intake.
The ADA continues to emphasize the importance of sustained, moderate weight loss and increased physical activity for obese or overweight people.
“It is about healthy and sustainable weight loss,” Albright said.
Advantages, disadvantages of TZDs
The recent update to the consensus algorithm that was originally issued by the ADA and European Association for the Study of Diabetes in 2006 concerns use of TZDs.
“The committee shares concern with the FDA and [others] that TZDs need to be considered more cautiously in that second step of the algorithm,” David M. Nathan, MD, director, Diabetes Center at Massachusetts General Hospital, told Endocrine Today.
The algorithm included TZDs as one of three choices for patients with type 2 diabetes, in addition to insulin and sulfonylurea, that can be added to treatment with metformin. The update was published in response to the release of meta-analyses questioning the safety of TZDs, specifically rosiglitazone and pioglitazone.
“Because of recent concern with rosiglitazone with regard to ischemic heart disease, we thought that clinicians should be cautioned,” Nathan said.
According to the update, “the putative 30% to 40% relative increase in risk of myocardial infarction is based on data that are widely viewed as less than definitive.” TZDs also have been associated with fluid retention and increased fracture rate.
“Following our deliberations, there were two black box warnings added – one in general for congestive heart failure and one specifically for rosiglitazone and ischemic heart events. Obviously we needed to modify the algorithm to express our caution regarding TZDs in general,” he said. – by Katie Kalvaitis
The 2008 nutrition recommendations for diabetes are excellent and provide a guideline for practitioners in every aspect of nutrition management. As a diabetes educator in current practice, the guidelines provide an excellent tool to help educate and guide practice. The 2008 recommendations have been broadened to enlighten health care providers on current strategies for nutritional management of diabetes. One example would be the acknowledgement of the popular use of low-carbohydrate diets. The recommendations provide health care providers with guidelines for usage and monitoring of these low-carbohydrate meal plans.
– Donna Rice, RN, BSN, CDE
Endocrine Today Editorial Board member
Healthy nutrition and interventions for patients with diabetes |
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For more information:
- Bantle JP, Wylie-Rosett J, Albright AL, et al. Nutrition recommendations and interventions for diabetes. Diabetes Care. 2008;31:561-578.
- Nathan DM, Buse JB, Davidson MB, et al. Management of hyperglycemia in type 2 diabetes: A consensus algorithm for the initiation and adjustment of therapy. Diabetes Care. 2008;31:173-175.