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Diabetes educators, patients must collaborate on individualized medical nutrition therapy
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INDIANAPOLIS — Medical nutrition therapy is an effective strategy for the treatment of type 2 diabetes, yet dietetic professionals are not doing enough to “shout from the mountaintops” that nutrition therapy can lower HbA1c, according to a speaker here.
Speaking at the American Association of Diabetes Educators annual meeting, Alison Evert, MS, RD, CDE, manager of nutrition and diabetes education programs at the University of Washington Neighborhood Clinics in Seattle, stressed that for medical nutrition therapy, or MNT, to be effective, it must be individualized in a collaborative way to meet the needs of the person the dietician or certified diabetes educator is working with. A single nutrition intervention, Evert said, cannot work with every patient, and new, emerging research means trends and recommendations are often changing.
“Nutrition is a science, just like other fields of medicine,” Evert told Endocrine Today before her presentation. “Therefore, nutrition interventions change over time based on new research. We owe it to our patients and clients to stay up to date.”
Focus on lifestyle
The changes can be confusing not just for patients, but for diabetes educators and dietitians as well, Evert said. She recalled recommending that her patients opt for margarine over butter in the 1980s, as that was prevailing wisdom of the time.
“We know now that trans fats are not good for us,” Evert said. “It doesn’t mean that what we were doing then was wrong. It means science has evolved and our recommendations have changed.”
But some recommendations do not put enough of a focus on lifestyle as medicine, Evert said. She pointed to a 16-page position statement released by the American Diabetes Association and the European Association for the Study of Diabetes on evidence-based strategies for people with type 2 diabetes. In the recommendations, just six paragraphs were devoted to lifestyle intervention, Evert said.
“But the evidence shows that, for all people — not just people with an [HbA1c] under 7.5% — it all begins with lifestyle intervention,” Evert said. “And, of course [this includes] a healthful meal plan as a part of that reduced energy intake, and, a very important component of behavioral support.”
Evert, who also worked on the evidence analysis library update for the Academy of Nutrition and Dietetics, published in December 2015, said research shows that nutrition therapy is an effective strategy for type 2 diabetes, yet medical nutrition therapy is underutilized.
“The Academy also looked at what meal planning strategies are the most effective,” Evert said. “We know from the research that the carbohydrate intake and the available insulin are the primary determinants of the postprandial glucose rise. Therefore, managing the intake is a primary strategy for people with type 2 diabetes.”
Carbs can vary
In the systematic review, researchers found that a variety of eating patterns or combinations of different food groups are acceptable for the management of diabetes. Dietitians, she said, should not feel a need to recommend specific carbohydrate intakes for men and women.
“What my fellow committee members found through our research review was the very often prescribed recommendation of [daily intake of] 30 to 45 grams of carbohydrates for women and [intake of] 45 to 60 grams carbohydrates for men ... we don’t have the research to support specific recommendations like that,” Evert said. Instead, Evert said, recommendations should be individualized to personal preferences, considering cultural, religious and health beliefs.
“Those are the meal planning strategies that work,” she said.
In addition, 87% of patients with type 2 diabetes have overweight or obesity, Evert said. These patients can expect weight loss plateaus and even weight regain, regardless of the intervention, and if treatment, ie, nutrition therapy, is discontinued, weight gain occurs. However, research reveals that, with ongoing support of the dietetic professional, modest weight loss can be maintained, Evert said. Any weight loss interventions, like food recommendations, are not the same for everyone. The common component, she said, is that any intervention needs to be intensive and include physical activity and behavioral support.
“The diet or meal plan needs to be energy reduced,” Evert said. “We need to help people learn how to maintain weight loss.” – by Regina Schaffer
Reference:
Evert A. Hot Topics in Nutrition Management and Dietary Patterns Across the Diabetes Spectrum. Presented at: American Association of Diabetes Educators; Aug. 4-7, 2017; Indianapolis.
Disclosures: Evert reports serving on the clinical advisory board for Senseonics.
Perspective
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Hope Warshaw, MMSc, RD, CDE, BC-ADM, FAADE
Nutrition researchers and diabetes health care providers have and continue to collectively spend an inordinate amount of time, energy and dollars in search of the one ideal diet for people with diabetes. Blend into the mix the misinformation and confusing advice people hear and see across multiple media channels. As Evert points out, nutrition is, like all sciences, evolving, and the reality is that to date there is no single eating plan right for all people with diabetes, regardless of type, and unlikely ever to be. This is based on our current evidence base. What we know about people’s eating habits and food choices, and what we’ve learned through research, are critical components to helping people achieve and maintain a healthier weight and eating habits to result in improved clinical outcomes. While it is easy for diabetes clinicians to throw up their hands and say that people don’t adhere to “diets,” it is critical to review the evidence base that demonstrates nutrition therapy can be clinically successful and cost-effective if implemented correctly. To implement nutrition therapy effectively means using evidence-based recommendations and an individualized approach based on that client’s current food choices, eating habits, willingness to make changes, and more. Last, but definitely not least, to effectively implement diabetes nutrition therapy, patients must work with a health care provider with diabetes expertise or other knowledgeable counselor on a frequent and regular basis. Unfortunately, today this rarely occurs due to lack of referral and or adequate reimbursement for services. This is how real and positive changes in food choices, eating habits, weight and diabetes care can and do happen.
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