Nutrition guidelines focus on individualized approach to patients with diabetes

In recent weeks, the field of endocrinology has been met with a burst of new clinical practice guidelines emphasizing proper nutrition and preventive strategies for the management of patients with diabetes. Meanwhile, the diet debate among policymakers and health care providers continues, with a controversial question of whether a government sales tax on high-calorie or sugary beverages could improve the prevalence of diabetes and obesity.

Endocrine Today spoke with authors of the new clinical practice guidelines to understand the impact on practicing endocrinologists. The American Association of Clinical Endocrinologists in conjunction with The Obesity Society released guidelines tackling the topic of healthy eating for the prevention and treatment of metabolic and endocrine disease in adults, whereas the American Diabetes Association addressed nutrition therapy for the management of adults with diabetes.

The comprehensive guidelines address various patient populations, AACE President Jeffrey I. Mechanick, MD, FACP, FACE, FACN, director of metabolic support in the division of endocrinology, diabetes and bone disease and clinical professor of medicine at Mount Sinai Medical Center, told Endocrine Today.

“One of the strongest components of preventive medicine is nutrition,” said Mechanick, a co-author on the AACE guidelines. “Medicine is moving toward a greater emphasis on preventive medicine rather than just waiting for the disease to occur. We would like to see a paradigm shift occur more often from disease management to disease prevention; that’s the premise.”

AACE/TOS guidelines on healthy eating

In the AACE/TOS guidelines on healthy eating, Mechanick and colleagues address overweight and obesity, adiposopathy, diabetes, chronic kidney disease, hypertension, dyslipidemia, bone health, pregnancy and lactation, and nutrient deficiencies in older adults.

“These guidelines are not just for clinical endocrinologists. Even though this document was written by clinical endocrinologists and physicians with a variety of specialties, it is designed for every member of the health care arena,” Mechanick said. “Nutrition is highly pervasive; it affects every aspect of health care. Any health care professional who is treating patients in a practical and even research setting will find something in the guidelines that will be of use to them.”

The group used the same AACE paradigm of evidence-based clinical practice guidelines, rehashing methods published in the 2010 guidelines, and provided evidence that is generally well-accepted, useful and relevant, according to Mechanick.

The document first asks providers to identify what healthy eating is in their general recommendations for healthy eating and disease prevention; recommend that patients with diabetes are educated about their condition, and adhere to specific protein, carbohydrate and fat intake.

“We use the term ‘healthy eating’ instead of diet for two reasons. First, it’s more accurate, and better reflects the current nutritional epidemiology metric, which is a healthy eating pattern. Second, the word ‘diet’ is stigmatized; people think of diets as being restrictive and punitive, whereas healthy eating is more of a positive connotation,” Mechanick said.

From bone health to age; gender to lactation, the guidelines attempt to cover all aspects of human nutrition, he said.

For bone health, it is recommended that premenopausal women and men take 1,000 mg calcium per day, and 1,200 mg/day to 1,500 mg/day for postmenopausal women.

The guidelines encourage exclusive breast-feeding for at least the first 6 months of life and all lactating women are recommended to ingest a minimum of 250 mcg iodine daily.

And for the frail elderly, the researchers recommend that community nutrition assistance programs that provide patients with home-delivered meals should be offered for elderly patients still living alone.

Providers also are encouraged to provide patients at risk for cardiovascular disease to increase caloric expenditure to at least 150 minutes of moderate-intensity activity each week or 75 minutes of vigorous-intensity activity every week. Weight loss and a change in meal plan are the two essential recommendations for this patient population.

“In issuing these guidelines, it is our intent to fill the medical gap that currently exists by defining evidence-based, necessary and specific clinical strategies for the prevention and treatment of a broad range of metabolic disorders in adults,” J. Michael Gonzalez-Campoy, MD, PhD, FACE, who co-chaired the AACE guidelines committee, said in a press release. “These comprehensive recommendations effectively address patient standards of care while also providing a worthwhile framework for disease prevention.”

ADA position statement on nutrition therapy

The ADA’s recently published position statement on nutrition therapy recommendations for the management of adults with diabetes recognizes that there is no “one-size-fits-all” approach, according to co-author Alison B. Evert, MS, RD, CDE, coordinator of diabetes education programs at the University of Washington Medical Center in Seattle.

“People don’t eat macronutrients; they eat food based on their ethnic, cultural and religious backgrounds. Trying to focus on helping patients eat the foods they want to, while helping them achieve health outcomes such as glycemic control, CV outcomes and lowering blood pressure,” Evert told Endocrine Today. “Nutritional therapies would allow them to do that.”

New to this set of guidelines is the first-time recommendation that patients with diabetes should limit or avoid sugar-sweetened beverages, according to Evert. In particular, patients with diabetes should be instructed to limit or avoid an intake of sugar-sweetened beverages from any caloric sweetener, including high-fructose corn syrup and sucrose, to decrease their risk for weight gain and CVD, according to the document.

Another recommendation states that the general population reduce sodium intake to less than 2,300 mg/day, which also is appropriate for patients with diabetes. However, this intake should be individualized for patients with hypertension, Evert said.

Although the position statement clearly explains that there is not enough evidence to determine an ideal amount of carbohydrate intake for patients with diabetes, Evert and colleagues suggest that carbohydrates should come from vegetables, whole grains, fruits, legumes and dairy products.

Similarly, the authors wrote that there is not enough evidence to suggest an ideal amount of total fat intake, that quality of the fat is more important than the quantity. Consumption of monounsaturated and polyunsaturated fats in addition to avoiding trans fats and saturated fats is recommended.

Furthermore, the review of research determined that patients with diabetes do not benefit from the use of omega-3 (EPA and DHA) supplements for the prevention or treatment of CV events.

“We know that nutrition therapy can be an effective treatment strategy for patients with diabetes,” Evert said.

“As the patient transitions from managing their diabetes with a ‘healthful eating pattern and physical activity’ to the addition of medications in order to optimize glycemic control, nutrition therapy continues to be an essential component of the treatment plan.”

There also is no conclusive evidence to support the beneficial effects of vitamin or mineral supplements for patients with diabetes who do not already have a vitamin or mineral deficiency, according to researchers.

Although some recent studies have suggested that cinnamon could be a potential therapy for diabetes, the researchers wrote that there is insufficient evidence to support the use of cinnamon or other herbs/supplements for the treatment of diabetes.

Unfortunately, findings from small clinical and animal studies are frequently extrapolated inappropriately to clinical practice, Evert said.

“Helping that individual patient find an eating plan or pattern that fits their preferences, their lifestyle, and something they can follow long term is the key. It’s not making things more complicated than it has to be,” Evert said. “Previous recommendations have said there is not ‘one ADA diet,’ but it comes down to individualizing it, creating a collaborative effort for an ongoing support system.”

The ‘diet’ debate continues

The dietary debate in the scientific community sheds little light on the treatment of obesity and diabetes, according to a viewpoint published in JAMA by Sherry L. Pagoto, PhD, of the University of Massachusetts Medical School in Worcester, and Bradley M. Appelhans, PhD, of Rush University Medical Center in Chicago. This ongoing debate tends to release mixed messages to the public, they added.

“There are two reasons the diet debates persist,” they wrote. “First, the commercialization potential of breakthrough diets is substantial. Fad diets have created a multibillion-dollar industry. The difference between fad diets is almost entirely related to macronutrient composition (eg, Zone, Atkins, South Beach, Dukan, Paleo).”

The second factor is the assumption that lifestyle interventions are ineffective, according to Pagoto and Appelhans. They wrote that poor adherence and subsequent weight regain is cited as evidence that these interventions do not work.

“This conclusion can be challenged because it assumes a definition for efficacy more stringent than that applied to other forms of preventive care,” they wrote.

In a paper by Daniela Dunkler, PhD, of the section of clinical biometrics and Center For Medical Statistics, Informatics, and Intelligent Systems at the Medical University of Vienna, and members of the Ongoing Telmisartan Alone and in Combination with Ramipril Global Endpoint Trial (ONTARGET), it was reported that a healthy diet and moderate intake of alcohol may decrease the incidence or progression of CKD among patients with type 2 diabetes. Moreover, they found that sodium intake within a wide range and normal protein intake were not associated with CKD.

In an invited commentary to a paper published in JAMA Internal Medicine, Holly Kramer, MD, MPH, of the department of medicine and public health sciences at Loyola University Chicago, and Alex Chang, MD, MS, of Johns Hopkins University, wrote that dietary recommendations for patients with type 2 diabetes have been varied and contradictory.

“Patients with both type 2 diabetes and kidney disease might be frustrated by the numerous dietary restrictions that are recommended by their health care team,” Kramer and Chang wrote. “Patients may even ask ‘what can I eat?’ Perhaps the best dietary advice we can give to patients with type 2 diabetes and kidney disease is the same as the advice who want to avoid CKD, and the same advice for preventing and treating hypertension, and the same dietary advice for everyone: eat a diet rich in fruits and vegetables, low-fat dairy products, and whole grains while minimizing saturated and total fat.”

Evert did note that patients with CKD may also be restricted as to their fruit and vegetable intake depending on their individual nutrition goals.

In an interview with Endocrine Today, Kramer said there is misinformation, and oftentimes, patients are being cared for by a variety of health care providers who are giving them different levels of dietary advice.

“No one is really talking to each other, and we need to come together with a simple, unified message. We need to have a simple message for people with diabetes, and simplicity and parsimony would best benefit the patient rather than a complicated formula,” Kramer said. “It’s time to get back to the basics.”

Research recently published in Diabetologia by Diewertje Sluik, DrPH, of the department of epidemiology, German Institute of Human Nutrition in Potsdam-Rehbruecke, Germany, also suggests that diet and lifestyle advice for those with diabetes should be no different than for the general public.

Using the European Prospective Investigation into Cancer and Nutrition (EPIC), the study consisted of a cohort of 6,384 patients with diabetes and 258,911 patients without diabetes.

“We did not find that diabetes status substantially influenced the associations between lifestyle and mortality risk, which means lifestyle recommendations, including diet, should not differ for people with diabetes compared with the general public,” Sluik told Endocrine Today.

Sugar tax remains controversial

Increasing the cost of high-calorie beverages could affect calorie intake, according to Jason P. Block, MD, of Harvard Medical School’s department of population medicine. Block told Endocrine Today about a recent study he presented at Obesity Week 2013, which demonstrated that a sugar tax was associated with significantly consistent decreased sales of high-calorie beverages.

“The reason to test these types of interventions is to potentially look at whether or not there are things we can do on a macro level — environmental interventions and fiscal interventions on a large scale — to see if they’ll have any impact on calorie intake,” Block said.

In response to the ADA position statement, which recommends that patients avoid sugary beverages, Block said, “They’re right on target,” adding that sugary beverage intake is a large contributor to the obesity epidemic.

“Whatever we can do to encourage people to drink less [sugar-sweetened drinks] and getting to the goal of drinking none is a positive. In many ways, sugary beverages are uniquely bad in terms of contributing to weight gain, just because the body doesn’t fully compensate for those calories, doesn’t recognize those calories, and it’s just typically an added calorie to what patients are already eating,” Block said.

The debate on artificial sweeteners remains controversial. Could a sugar tax really affect the prevalence of diabetes and other endocrine diseases? Block said a tax would have an important effect across a population in terms of the rates of diabetes and obesity. He suggests a 20% tax.

“We can’t just expect a soda or sugary beverage tax to solve the obesity problem. It’s not going to do that, but it is part of a bigger comprehensive approach. We also need good data; we need a state or country to implement a high tax, so that we can measure the impact of it and put the debate to bed. Right now, there’s still some speculation about what the effect of it would actually be. We won’t know what it will actually be until we have an example,” Block said.

Challenges for diabetes educators

Ann Constance, MA, RD, CDE, FAADE, director of the Upper Peninsula Diabetes Outreach Network in Marquette, Mich., is practicing in a 15-county rural area. There, setting up group sessions and follow-up care for patients with diabetes can be challenging due to the long distance needed to travel, conflicting work schedules and policy requirements.

“Too many people are just out there languishing, and may not feel as good as they used to feel, but don’t know how good they could feel. They don’t know that the path they’re on could lead to more complications because their blood pressure, lipids or glucose is not being adequately controlled,” Constance said.

She said policy issues often get in the way of treating patients, citing the home-delivered meals suggested by the TOS/AACE guidelines as an example.

“We need some policy changes in terms of how things are reimbursed and how we can offer services to make it most convenient for the patient with diabetes,” Constance said. “The Institute of Medicine supports the role of RD/RDN and medical nutrition therapy in helping to improve diabetes outcomes and potentially lowering Medicare expenditure on diabetes; this is a service that is vastly underutilized.”

She said the ADA guidelines cited the role of public health and community in diabetes support. However, there is no clear role for either.

Evert, also a diabetes educator, and colleagues wrote that future research studies should address: relationships between eating patterns and disease in diverse populations; benefits of a Mediterranean-style eating pattern; standardized definitions for high- and low-glycemic index diets and low- to moderate-carbohydrate diets; whether nonnutritive sweeteners are useful in reducing caloric and carbohydrate intake; the impact of key nutrients on CV risk; and the intake of saturated fatty acid and its relationship to insulin resistance. – by Samantha Costa

Is a carbohydrate-restricted diet safe and efficacious to prescribe for women with gestational diabetes?

75 g of carbohydrates lessens the need for insulin treatment

We restrict carbohydrates in the meal plan because the fetus is at risk for harm secondary to the highest blood glucose concentration. The peak postprandial response occurs at 1 hour after eating which can be minimized if the meal plan is devoid of bread, rice, pasta, cereal, potatoes or tortillas. The only fruit we allow are lemons and limes. We ask our women to take multivitamins to assure that our restricted carbohydrate meals do not cause vitamin deficiency.

Breakfast is the most difficult meal to maintain the post prandial peak in target (less than 120 mg/dL). This excessive rise in blood glucose concentration is potentiated by the Dawn phenomenon (the hormones that wake us up in the morning; chiefly, cortisol) and the placental anti-insulin hormones (chiefly, progesterone and human placental lactogen). Thus, breakfast is prescribed as only protein, fat and raw vegetables. With this carbohydrate-restricted diet, which is less than 15 grams of carbohydrates for breakfast and less than 30 grams of carbohydrates for lunch and dinner, fewer than 20% of our patients with gestational diabetes need insulin treatment.

Lois Jovanovic, MD, is an Endocrine Today Editorial Board Member and the chief scientific officer at Sansum Diabetes Research Institute. She can be reached at 2219 Bath St., Santa Barbara, California 93105; email: ljovanovic@sansum.org. She reports no relevant financial disclosures.

We do not have enough evidence to define the safety of such a diet

I don’t know if it’s safe or not safe, I just know it’s not necessary. We do not have enough evidence to really define the safety of such a diet.

Our first concern when implementing a nutrition therapy intervention is a healthy eating pattern. Patients with diabetes deserve the right to eat healthily; as do women with gestational diabetes. Certainly, carbohydrates are healthy foods (ie, fruits, vegetables, milk, whole grains).

Women with gestational diabetes should follow the same guidelines for healthy eating that any woman follows during pregnancy. It’s important to understand what matters from the standpoint of implementing a nutrition therapy intervention and if a reduced energy intake could help women eat healthier or less.

In a recent study, researchers found no advantage to a low carbohydrate diet as far as outcomes; it didn’t reduce the number of women requiring insulin, while producing similar pregnancy outcomes.

What really matters is how much women with gestational diabetes eat. It has been shown in research that the pregnant women can safely reduce the amount of caloric intake without having an impact on pregnancy outcomes. Usually, a caloric intake can be reduced by about 30%. Intakes of about 1,700 to 1,800 calories are suitable.

When we look at patients with type 2 diabetes, it’s not the macronutrient diet that matters; it is how much people eat. That’s what I think is important for women with gestational diabetes as well.

Marion J. Franz, MS, RD, CDE, is a nutrition and health consultant with Nutrition Concepts by Franz Inc. She can be reached at 6635 Limerick Dr., Minneapolis, MN 55439; email: MarionFranz@aol.com. She reports no relevant financial disclosures.

Adult women should consume 45% to 65% of their calories from carbohydrates

The 2002 Institute of Medicine Dietary Reference Intake Report set a minimum level of 175 grams of carbohydrate per day for pregnant women, 33 g per day more than for non-pregnant women. To give this relevance, 33 g of carbohydrates is a large apple or banana. With no consideration of individualizing the medicine/diet therapy, it is arbitrary. Carbohydrates — like calories — should be based on individual needs. Of course, the lower carbohydrate content diets are associated with less need for insulin to manage hyperglycemia.

The IOM recommendation is not accounting for an individualized meal plan or needs for the pregnant woman. Depending upon the pregnant woman’s estimated caloric need, will the 175 g be classified as a “low/restricted?” For example, if I have a female patient whose caloric need during pregnancy is 2,000 calories, total calories from carbohydrates (175 g) are 35%; if it is 1,800 calories then total calories from carbohydrates are 39%; if the need is 2,200 calories, 32% of the total calories will come from carbohydrates. According to the IOM, adult women (non-pregnant) should consume 45% to 65% of their daily calories from carbohydrates. This means women following 1,200-calorie weight loss diets need about 135 g to 195 g of carbohydrates each day; women consuming 1,600-calorie diets need to consume 180 g to 260 g; women following 2,000-calorie diets need 225 g to 325 g, and women consuming 2,400 calories per day require 270 g to 390 g of carbohydrates each day.

Rose J. Prissel, RD, LD, is a clinical registered dietician in the diabetes unit of the Mayo Clinic in Rochester. She can be reached at 200 First Street SW, Rochester, MN 55905; email: prissel.rose@mayo.edu. She reports no relevant financial disclosures.